Provider Demographics
NPI:1194853028
Name:MAYNARD, SHARON F (RD)
Entity Type:Individual
Prefix:MRS
First Name:SHARON
Middle Name:F
Last Name:MAYNARD
Suffix:
Gender:F
Credentials:RD
Other - Prefix:MISS
Other - First Name:SHARON
Other - Middle Name:L
Other - Last Name:FULKS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:117 WINCHESTER DR
Mailing Address - Street 2:
Mailing Address - City:CULLODEN
Mailing Address - State:WV
Mailing Address - Zip Code:25510-9660
Mailing Address - Country:US
Mailing Address - Phone:304-766-4329
Mailing Address - Fax:304-766-3672
Practice Address - Street 1:4605 MACCORKLE AVE SW
Practice Address - Street 2:
Practice Address - City:SOUTH CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25309-1311
Practice Address - Country:US
Practice Address - Phone:304-766-4329
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV04133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered