Provider Demographics
NPI:1265877880
Name:MAYNARD, LESLIE MARIE (APRN)
Entity type:Individual
Prefix:
First Name:LESLIE
Middle Name:MARIE
Last Name:MAYNARD
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3050 RIO DOSA DR
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40509-1540
Mailing Address - Country:US
Mailing Address - Phone:859-268-6410
Mailing Address - Fax:859-268-6473
Practice Address - Street 1:3050 RIO DOSA DR
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40509-1540
Practice Address - Country:US
Practice Address - Phone:859-268-6410
Practice Address - Fax:859-268-6473
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-09
Last Update Date:2015-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3008043363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY1790731081Medicaid