Provider Demographics
NPI:1356925820
Name:MAYNARD, BRIAN (DNP, FNP-BC)
Entity type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:
Last Name:MAYNARD
Suffix:
Gender:M
Credentials:DNP, FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2986 W 2600 S
Mailing Address - Street 2:
Mailing Address - City:WEST HAVEN
Mailing Address - State:UT
Mailing Address - Zip Code:84401-5006
Mailing Address - Country:US
Mailing Address - Phone:801-589-0631
Mailing Address - Fax:
Practice Address - Street 1:630 E 1400 N
Practice Address - Street 2:
Practice Address - City:LOGAN
Practice Address - State:UT
Practice Address - Zip Code:84341-2691
Practice Address - Country:US
Practice Address - Phone:435-915-4465
Practice Address - Fax:435-799-3664
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-10
Last Update Date:2023-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT348531-4405363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty