Provider Demographics
NPI:1932665858
Name:MAYNARD, AMY KIRSTEN (RN, MS, CCCRN, CCNS)
Entity Type:Individual
Prefix:MS
First Name:AMY
Middle Name:KIRSTEN
Last Name:MAYNARD
Suffix:
Gender:F
Credentials:RN, MS, CCCRN, CCNS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2158 15TH AVE E
Mailing Address - Street 2:
Mailing Address - City:NORTH ST PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55109-5125
Mailing Address - Country:US
Mailing Address - Phone:612-309-2397
Mailing Address - Fax:763-236-4244
Practice Address - Street 1:550 OSBORNE RD NE
Practice Address - Street 2:
Practice Address - City:FRIDLEY
Practice Address - State:MN
Practice Address - Zip Code:55432-2718
Practice Address - Country:US
Practice Address - Phone:763-236-4235
Practice Address - Fax:763-236-4244
Is Sole Proprietor?:No
Enumeration Date:2019-02-15
Last Update Date:2019-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR095590-6163WC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC0200XNursing Service ProvidersRegistered NurseCritical Care Medicine