Provider Demographics
NPI:1851703599
Name:MAYNES, LISA ANN
Entity Type:Individual
Prefix:MS
First Name:LISA
Middle Name:ANN
Last Name:MAYNES
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:LISA
Other - Middle Name:ANN
Other - Last Name:MAYNES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:348 S HIGHWAY 1223
Mailing Address - Street 2:
Mailing Address - City:CORBIN
Mailing Address - State:KY
Mailing Address - Zip Code:40701-4643
Mailing Address - Country:US
Mailing Address - Phone:606-521-7045
Mailing Address - Fax:
Practice Address - Street 1:348 S HIGHWAY 1223
Practice Address - Street 2:
Practice Address - City:CORBIN
Practice Address - State:KY
Practice Address - Zip Code:40701-4643
Practice Address - Country:US
Practice Address - Phone:606-521-7045
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-05-29
Last Update Date:2016-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYM94719254174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist