Provider Demographics
NPI:1164025920
Name:MAINVILLE, JAMIE LYNN (NP)
Entity Type:Individual
Prefix:
First Name:JAMIE
Middle Name:LYNN
Last Name:MAINVILLE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11113 W TURNEY AVE
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85037-5319
Mailing Address - Country:US
Mailing Address - Phone:602-903-0199
Mailing Address - Fax:
Practice Address - Street 1:11113 W TURNEY AVE
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85037-5319
Practice Address - Country:US
Practice Address - Phone:602-903-0199
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-16
Last Update Date:2020-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ250087363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily