Provider Demographics
NPI:1518481308
Name:MAYNARD, TYLER LEIGH
Entity Type:Individual
Prefix:
First Name:TYLER
Middle Name:LEIGH
Last Name:MAYNARD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:TYLER
Other - Middle Name:
Other - Last Name:SHUMARD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO DRAWER 2109
Mailing Address - Street 2:
Mailing Address - City:RUSSELLVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72811
Mailing Address - Country:US
Mailing Address - Phone:479-967-2322
Mailing Address - Fax:
Practice Address - Street 1:908 N REYNOLDS RD
Practice Address - Street 2:
Practice Address - City:BRYANT
Practice Address - State:AR
Practice Address - Zip Code:72022-3034
Practice Address - Country:US
Practice Address - Phone:501-847-9711
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-02
Last Update Date:2023-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR4232225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR238537721Medicaid