Provider Demographics
NPI:1629579727
Name:MAYNARD, REGINA WYNNE
Entity Type:Individual
Prefix:
First Name:REGINA
Middle Name:WYNNE
Last Name:MAYNARD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2021 SPANISH TRL
Mailing Address - Street 2:
Mailing Address - City:CORPUS CHRISTI
Mailing Address - State:TX
Mailing Address - Zip Code:78410-1307
Mailing Address - Country:US
Mailing Address - Phone:361-241-3232
Mailing Address - Fax:
Practice Address - Street 1:2021 SPANISH TRL
Practice Address - Street 2:
Practice Address - City:CORPUS CHRISTI
Practice Address - State:TX
Practice Address - Zip Code:78410-1307
Practice Address - Country:US
Practice Address - Phone:361-241-3232
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-23
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX113464164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse