Provider Demographics
NPI:1144838814
Name:MAYNARD, SARA KATHERINE
Entity type:Individual
Prefix:
First Name:SARA
Middle Name:KATHERINE
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:PO BOX 718
Mailing Address - Street 2:
Mailing Address - City:CHAPMANVILLE
Mailing Address - State:WV
Mailing Address - Zip Code:25508-0718
Mailing Address - Country:US
Mailing Address - Phone:304-601-5016
Mailing Address - Fax:
Practice Address - Street 1:1000 MYERS AVE APT 304
Practice Address - Street 2:
Practice Address - City:DUNBAR
Practice Address - State:WV
Practice Address - Zip Code:25064-3140
Practice Address - Country:US
Practice Address - Phone:304-601-5016
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-20
Last Update Date:2020-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV00602134346Medicaid