Provider Demographics
NPI:1619459815
Name:MAYNOR, BRIANA (ARNP)
Entity Type:Individual
Prefix:
First Name:BRIANA
Middle Name:
Last Name:MAYNOR
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:BRIANA
Other - Middle Name:
Other - Last Name:ST. CLAIR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 32
Mailing Address - Street 2:
Mailing Address - City:LIBERTY LAKE
Mailing Address - State:WA
Mailing Address - Zip Code:99019-0032
Mailing Address - Country:US
Mailing Address - Phone:866-747-2455
Mailing Address - Fax:
Practice Address - Street 1:380 CHASE AVE
Practice Address - Street 2:
Practice Address - City:WALLA WALLA
Practice Address - State:WA
Practice Address - Zip Code:99362-2924
Practice Address - Country:US
Practice Address - Phone:509-897-3050
Practice Address - Fax:509-897-5899
Is Sole Proprietor?:No
Enumeration Date:2018-09-04
Last Update Date:2021-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP60838552363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2107015Medicaid