Provider Demographics
NPI:1457876658
Name:MAYNARD, ALEXANDRA ANTONIA (CRNA)
Entity type:Individual
Prefix:MRS
First Name:ALEXANDRA
Middle Name:ANTONIA
Last Name:MAYNARD
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:140 NATIVE CIR
Mailing Address - Street 2:
Mailing Address - City:BENTON
Mailing Address - State:KY
Mailing Address - Zip Code:42025-7167
Mailing Address - Country:US
Mailing Address - Phone:270-227-4968
Mailing Address - Fax:
Practice Address - Street 1:2501 KENTUCKY AVE
Practice Address - Street 2:
Practice Address - City:PADUCAH
Practice Address - State:KY
Practice Address - Zip Code:42003-3813
Practice Address - Country:US
Practice Address - Phone:270-575-2100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-08
Last Update Date:2017-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3011651367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered