Provider Demographics
NPI:1730105792
Name:MAYNARD, JO ANNE (DNP)
Entity Type:Individual
Prefix:MS
First Name:JO ANNE
Middle Name:
Last Name:MAYNARD
Suffix:
Gender:F
Credentials:DNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:650 COMMACK RD
Mailing Address - Street 2:
Mailing Address - City:COMMACK
Mailing Address - State:NY
Mailing Address - Zip Code:11725-5404
Mailing Address - Country:US
Mailing Address - Phone:631-495-5295
Mailing Address - Fax:631-675-2001
Practice Address - Street 1:740 COUNTY ROAD 39A
Practice Address - Street 2:
Practice Address - City:SOUTHAMPTON
Practice Address - State:NY
Practice Address - Zip Code:11968-5247
Practice Address - Country:US
Practice Address - Phone:631-638-7702
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-14
Last Update Date:2019-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF301032363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02376410Medicaid
NY0119GXRWT1Medicare PIN
NY02376410Medicaid