Provider Demographics
NPI:1144699810
Name:MAYNARD, NITZA
Entity type:Individual
Prefix:
First Name:NITZA
Middle Name:
Last Name:MAYNARD
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 1:43 LIBERTY DR
Mailing Address - Street 2:
Mailing Address - City:AMSTERDAM
Mailing Address - State:NY
Mailing Address - Zip Code:12010-5635
Mailing Address - Country:US
Mailing Address - Phone:518-993-3175
Mailing Address - Fax:
Practice Address - Street 1:204 CANAL ST
Practice Address - Street 2:
Practice Address - City:FORT PLAIN
Practice Address - State:NY
Practice Address - Zip Code:13339-1119
Practice Address - Country:US
Practice Address - Phone:518-993-3175
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-09-23
Last Update Date:2015-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY004412-1224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant