Provider Demographics
NPI:1144620352
Name:MAYNARD, DEBRA HILL (MS, RDN)
Entity Type:Individual
Prefix:
First Name:DEBRA
Middle Name:HILL
Last Name:MAYNARD
Suffix:
Gender:F
Credentials:MS, RDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12213 SHADOW RIDGE LN
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28273-4748
Mailing Address - Country:US
Mailing Address - Phone:704-622-9546
Mailing Address - Fax:
Practice Address - Street 1:12213 SHADOW RIDGE LN
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28273-4748
Practice Address - Country:US
Practice Address - Phone:704-622-9546
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-26
Last Update Date:2014-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCL001376133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered