Provider Demographics
NPI:1043854839
Name:MAYNARD, MELISSA FAY (RN)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:FAY
Last Name:MAYNARD
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2632 MARYLAND ST
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:WA
Mailing Address - Zip Code:98632-3557
Mailing Address - Country:US
Mailing Address - Phone:360-751-6124
Mailing Address - Fax:
Practice Address - Street 1:2632 MARYLAND ST
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:WA
Practice Address - Zip Code:98632-3557
Practice Address - Country:US
Practice Address - Phone:360-751-6124
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-05
Last Update Date:2019-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WARN60822165163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse