Provider Demographics
NPI:1881949576
Name:MAYNARD - WATTS, ADELLE ALEXANDRIA (DO)
Entity type:Individual
Prefix:DR
First Name:ADELLE
Middle Name:ALEXANDRIA
Last Name:MAYNARD - WATTS
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1301 CLOVER CT
Mailing Address - Street 2:
Mailing Address - City:TERRE HAUTE
Mailing Address - State:IN
Mailing Address - Zip Code:47802-9042
Mailing Address - Country:US
Mailing Address - Phone:812-201-5561
Mailing Address - Fax:
Practice Address - Street 1:1739 N 4TH ST
Practice Address - Street 2:
Practice Address - City:TERRE HAUTE
Practice Address - State:IN
Practice Address - Zip Code:47804-4002
Practice Address - Country:US
Practice Address - Phone:812-242-1000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-18
Last Update Date:2016-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
IN02004787A2084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program