Provider Demographics
NPI:1508254954
Name:CINDY A MAYBERRY APN LLC
Entity Type:Organization
Organization Name:CINDY A MAYBERRY APN LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NURSE PRACTITIONER
Authorized Official - Prefix:
Authorized Official - First Name:CINDY
Authorized Official - Middle Name:
Authorized Official - Last Name:MAYBERRY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:660-665-3545
Mailing Address - Street 1:705 E LAHARPE ST STE D
Mailing Address - Street 2:
Mailing Address - City:KIRKSVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:63501-4526
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:705 E LAHARPE ST STE D
Practice Address - Street 2:
Practice Address - City:KIRKSVILLE
Practice Address - State:MO
Practice Address - Zip Code:63501-4526
Practice Address - Country:US
Practice Address - Phone:660-665-3545
Practice Address - Fax:660-665-3226
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-01-07
Last Update Date:2015-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO100516364SP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes364SP0808XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
633829OtherCOM
MO182570OtherBLUE CROSS/BLUE SHIELD
MO429173503Medicaid
MO429173503Medicaid
000081731Medicare PIN