Provider Demographics
NPI:1083090849
Name:MAYNARD, MICHAELA ANN (APRN)
Entity Type:Individual
Prefix:
First Name:MICHAELA
Middle Name:ANN
Last Name:MAYNARD
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1125 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02904-5739
Mailing Address - Country:US
Mailing Address - Phone:401-793-2928
Mailing Address - Fax:
Practice Address - Street 1:1125 N MAIN ST
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02904-5739
Practice Address - Country:US
Practice Address - Phone:401-793-2928
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-04
Last Update Date:2019-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN2302797363LA2200X
RICAPRN01596363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health