Provider Demographics
NPI:1417651746
Name:MAYNARD, NICOLE PAIGE (MD)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:PAIGE
Last Name:MAYNARD
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3800 W CHAPMAN AVE STE 500
Mailing Address - Street 2:
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92868-1638
Mailing Address - Country:US
Mailing Address - Phone:714-456-5770
Mailing Address - Fax:
Practice Address - Street 1:3800 W CHAPMAN AVE STE 500
Practice Address - Street 2:
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92868-1638
Practice Address - Country:US
Practice Address - Phone:714-456-5902
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-29
Last Update Date:2023-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program