Provider Demographics
NPI:1689897886
Name:MAYNARD, JAMILEY C (FNP)
Entity Type:Individual
Prefix:
First Name:JAMILEY
Middle Name:C
Last Name:MAYNARD
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2723 S 7TH ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:TERRE HAUTE
Mailing Address - State:IN
Mailing Address - Zip Code:47802-3558
Mailing Address - Country:US
Mailing Address - Phone:812-238-1730
Mailing Address - Fax:812-242-1565
Practice Address - Street 1:2723 S 7TH STREET
Practice Address - Street 2:SUITE C
Practice Address - City:TERRE HAUTE
Practice Address - State:IN
Practice Address - Zip Code:47802-3558
Practice Address - Country:US
Practice Address - Phone:812-232-5936
Practice Address - Fax:812-235-1290
Is Sole Proprietor?:No
Enumeration Date:2007-04-10
Last Update Date:2014-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71001096A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200822620Medicaid
IN200822620Medicaid
P23993Medicare UPIN