Provider Demographics
NPI:1861979510
Name:HAYNES, CASSANDRA ELIZABETH
Entity type:Individual
Prefix:
First Name:CASSANDRA
Middle Name:ELIZABETH
Last Name:HAYNES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2799 W GRAND BLVD
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48202-2608
Mailing Address - Country:US
Mailing Address - Phone:888-777-4167
Mailing Address - Fax:313-464-5027
Practice Address - Street 1:2799 W GRAND BLVD
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48202-2608
Practice Address - Country:US
Practice Address - Phone:888-777-4167
Practice Address - Fax:313-464-5027
Is Sole Proprietor?:No
Enumeration Date:2018-07-25
Last Update Date:2023-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601011703363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant