1639882426 NPI number — DR. EBONI SHAVONE RAINEY-HAYNES

Table of content: DR. EBONI SHAVONE RAINEY-HAYNES (NPI 1639882426)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639882426 NPI number — DR. EBONI SHAVONE RAINEY-HAYNES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
RAINEY-HAYNES
Provider First Name:
EBONI
Provider Middle Name:
SHAVONE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
RAINEY
Provider Other First Name:
EBONI
Provider Other Middle Name:
S
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
DR
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1639882426
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/27/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
851 W STATE ROAD 436 STE 1005
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ALTAMONTE SPRINGS
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32714-3055
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
407-383-0643
Provider Business Mailing Address Fax Number:
407-266-0977

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
851 W STATE ROAD 436 STE 1005
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ALTAMONTE SPRINGS
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32714-3055
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
407-383-0643
Provider Business Practice Location Address Fax Number:
407-266-0977
Provider Enumeration Date:
12/27/2022

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  FB9767225 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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