Provider Demographics
NPI:1710551650
Name:MAYNARD, TAMARA LEA (APRN)
Entity Type:Individual
Prefix:
First Name:TAMARA
Middle Name:LEA
Last Name:MAYNARD
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 1:18934 N DALE MABRY HWY STE 101
Mailing Address - Street 2:
Mailing Address - City:LUTZ
Mailing Address - State:FL
Mailing Address - Zip Code:33548-4914
Mailing Address - Country:US
Mailing Address - Phone:813-948-2679
Mailing Address - Fax:813-948-2694
Practice Address - Street 1:18934 N DALE MABRY HWY STE 101
Practice Address - Street 2:
Practice Address - City:LUTZ
Practice Address - State:FL
Practice Address - Zip Code:33548-4914
Practice Address - Country:US
Practice Address - Phone:813-948-2679
Practice Address - Fax:813-948-2694
Is Sole Proprietor?:No
Enumeration Date:2021-05-15
Last Update Date:2022-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11012054363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics