1902166259 NPI number — JESYCA R HAINES CRNA

Table of content: JESYCA R HAINES CRNA (NPI 1902166259)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1902166259 NPI number — JESYCA R HAINES CRNA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HAINES
Provider First Name:
JESYCA
Provider Middle Name:
R
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
CRNA
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1902166259
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/19/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 5074
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SIOUX FALLS
Provider Business Mailing Address State Name:
SD
Provider Business Mailing Address Postal Code:
57117-5074
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1601 SIOUX VALLEY DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LUVERNE
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
56156-4500
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
507-283-4476
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/21/2012

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: 367500000X , with the licence number:  CR000789 , registered in the state of SD ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 367500000X , with the licence number: D163533 , registered in the state of IA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 46022474348 , issued by the state of ( NE ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1902166259 . This is a "WELLMARK BCBS SD" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1902166259 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: P01103855 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( SD ) . This identifiers is of the category "OTHER".
  • Identifier: 1902166259 . This is a "BCBS MN" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1902166259 . This is a "DAKOTACARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1902166259 , issued by the state of ( SD ) . This identifiers is of the category "MEDICAID".




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