Provider Demographics
NPI:1700818283
Name:MAYBERRY, CYNTHIA ANN (APRN)
Entity Type:Individual
Prefix:
First Name:CYNTHIA
Middle Name:ANN
Last Name:MAYBERRY
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:705 E LAHARPE ST STE D
Mailing Address - Street 2:
Mailing Address - City:KIRKSVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:63501-4526
Mailing Address - Country:US
Mailing Address - Phone:660-665-3545
Mailing Address - Fax:660-665-3226
Practice Address - Street 1:705 E LAHARPE ST STE D
Practice Address - Street 2:
Practice Address - City:KIRKSVILLE
Practice Address - State:MO
Practice Address - Zip Code:63501-4526
Practice Address - Country:US
Practice Address - Phone:660-665-3545
Practice Address - Fax:660-665-3226
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-07
Last Update Date:2012-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO100516363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO182570OtherBLUE CROSS/BLUE SHIELD
633829OtherCOM
MO429173503Medicaid
633829OtherCOM
MOP98540Medicare UPIN