Provider Demographics
NPI:1114065869
Name:MAYNARD, STUART (PHD CRNP, CNS-PMH)
Entity Type:Individual
Prefix:DR
First Name:STUART
Middle Name:
Last Name:MAYNARD
Suffix:
Gender:M
Credentials:PHD CRNP, CNS-PMH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4500 N PARK AVE
Mailing Address - Street 2:SUITE 801 NORTH
Mailing Address - City:CHEVY CHASE
Mailing Address - State:MD
Mailing Address - Zip Code:20815-7239
Mailing Address - Country:US
Mailing Address - Phone:301-656-6605
Mailing Address - Fax:
Practice Address - Street 1:4500 N PARK AVE
Practice Address - Street 2:SUITE 801 NORTH
Practice Address - City:CHEVY CHASE
Practice Address - State:MD
Practice Address - Zip Code:20815-7239
Practice Address - Country:US
Practice Address - Phone:301-656-6605
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-02
Last Update Date:2010-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR066358363LP0808X, 364SP0808X
DCRN1008295363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No364SP0808XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDS53988Medicare UPIN