Provider Demographics
NPI:1184751331
Name:MAYNARD, CAROLYN K (PHD FNP)
Entity type:Individual
Prefix:PROF
First Name:CAROLYN
Middle Name:K
Last Name:MAYNARD
Suffix:
Gender:F
Credentials:PHD FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1252 GIVERNY CT
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:NC
Mailing Address - Zip Code:28027-8130
Mailing Address - Country:US
Mailing Address - Phone:704-788-4347
Mailing Address - Fax:
Practice Address - Street 1:1307 S CANNON BLVD
Practice Address - Street 2:
Practice Address - City:KANNAPOLIS
Practice Address - State:NC
Practice Address - Zip Code:28083-6232
Practice Address - Country:US
Practice Address - Phone:704-920-1000
Practice Address - Fax:704-920-1366
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-27
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC054700363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCZF0000099Medicaid