Provider Demographics
NPI:1023310612
Name:MAYNE, KAREN IRENE
Entity type:Individual
Prefix:
First Name:KAREN
Middle Name:IRENE
Last Name:MAYNE
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 1:625 S 300 E
Mailing Address - Street 2:
Mailing Address - City:BRIGHAM CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84302-2910
Mailing Address - Country:US
Mailing Address - Phone:435-723-3276
Mailing Address - Fax:435-723-8299
Practice Address - Street 1:90 E 200 N
Practice Address - Street 2:
Practice Address - City:LOGAN
Practice Address - State:UT
Practice Address - Zip Code:84321-4034
Practice Address - Country:US
Practice Address - Phone:435-752-0750
Practice Address - Fax:435-723-4851
Is Sole Proprietor?:Yes
Enumeration Date:2010-12-02
Last Update Date:2010-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT00000171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator