Provider Demographics
NPI:1447223714
Name:MAYNES, CYNTHIA J (FNP)
Entity Type:Individual
Prefix:
First Name:CYNTHIA
Middle Name:J
Last Name:MAYNES
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:CYNTHIA
Other - Middle Name:J
Other - Last Name:ANTOS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP
Mailing Address - Street 1:2570 NW EDENBOWER BLVD STE 100
Mailing Address - Street 2:
Mailing Address - City:ROSEBURG
Mailing Address - State:OR
Mailing Address - Zip Code:97471-6214
Mailing Address - Country:US
Mailing Address - Phone:541-677-7200
Mailing Address - Fax:541-229-3363
Practice Address - Street 1:2570 NW EDENBOWER BLVD
Practice Address - Street 2:SUITE 100
Practice Address - City:ROSEBURG
Practice Address - State:OR
Practice Address - Zip Code:97470-6220
Practice Address - Country:US
Practice Address - Phone:541-677-7200
Practice Address - Fax:541-229-3363
Is Sole Proprietor?:No
Enumeration Date:2006-02-08
Last Update Date:2011-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR200350126NP FNP-PP363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR022638Medicaid
R156356Medicare PIN