Provider Demographics
NPI:1790950251
Name:MAYNARD, LISA G
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:G
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 1:376 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:COVINGTON
Mailing Address - State:VA
Mailing Address - Zip Code:24426-1517
Mailing Address - Country:US
Mailing Address - Phone:540-962-4433
Mailing Address - Fax:
Practice Address - Street 1:376 W MAIN ST
Practice Address - Street 2:
Practice Address - City:COVINGTON
Practice Address - State:VA
Practice Address - Zip Code:24426-1517
Practice Address - Country:US
Practice Address - Phone:540-962-4433
Practice Address - Fax:540-962-4434
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-25
Last Update Date:2008-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0206009194332BX2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA009106049Medicaid
VA009106049Medicaid