Provider Demographics
NPI:1881141067
Name:MAYNARD, SHARON (PTA)
Entity type:Individual
Prefix:
First Name:SHARON
Middle Name:
Last Name:MAYNARD
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:139 EDWARD ST
Mailing Address - Street 2:
Mailing Address - City:MARISSA
Mailing Address - State:IL
Mailing Address - Zip Code:62257-3553
Mailing Address - Country:US
Mailing Address - Phone:618-406-8742
Mailing Address - Fax:
Practice Address - Street 1:11623 ARBOR ST STE 100
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68144-2981
Practice Address - Country:US
Practice Address - Phone:402-334-6090
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-06
Last Update Date:2023-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL160004919225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant