Provider Demographics
NPI:1629456389
Name:MAYBERRY, EARL III (RN)
Entity Type:Individual
Prefix:MR
First Name:EARL
Middle Name:
Last Name:MAYBERRY
Suffix:III
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2205 W 36TH AVE
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:KS
Mailing Address - Zip Code:66103-2107
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2205 W 36TH AVE
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:KS
Practice Address - Zip Code:66103-2107
Practice Address - Country:US
Practice Address - Phone:913-956-5620
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-14
Last Update Date:2015-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS13-75191163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse