Provider Demographics
NPI:1720449952
Name:GAYNOR, CHARMAINE MUIR
Entity Type:Individual
Prefix:
First Name:CHARMAINE
Middle Name:MUIR
Last Name:GAYNOR
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 1:5211 NW
Mailing Address - Street 2:MAYFIELD LANE
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34983
Mailing Address - Country:US
Mailing Address - Phone:772-446-4747
Mailing Address - Fax:
Practice Address - Street 1:5211 NW MAYFIELD LN
Practice Address - Street 2:
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34983-5348
Practice Address - Country:US
Practice Address - Phone:772-446-4747
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-03-16
Last Update Date:2016-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
No376K00000XNursing Service Related ProvidersNurse's Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL004701500Medicaid