Provider Demographics
NPI:1093049470
Name:MAYNOR, JULIANNA (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:
First Name:JULIANNA
Middle Name:
Last Name:MAYNOR
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2845 E HIGHWAY 76
Mailing Address - Street 2:SUITE 5
Mailing Address - City:MULLINS
Mailing Address - State:SC
Mailing Address - Zip Code:29574-6037
Mailing Address - Country:US
Mailing Address - Phone:843-431-2650
Mailing Address - Fax:843-431-2647
Practice Address - Street 1:2845 E HIGHWAY 76
Practice Address - Street 2:SUITE 5
Practice Address - City:MULLINS
Practice Address - State:SC
Practice Address - Zip Code:29574-6037
Practice Address - Country:US
Practice Address - Phone:843-431-2650
Practice Address - Fax:843-431-2647
Is Sole Proprietor?:No
Enumeration Date:2009-10-01
Last Update Date:2012-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC3872363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP5462OtherMEDICAID GROUP
SCRHC 121Medicaid
SCNP0619Medicaid
SCGP5462OtherMEDICAID GROUP
SCNP0619Medicaid
SCAA57899493Medicare PIN