Provider Demographics
NPI:1205071743
Name:MAYNARD, JUNETTA A (FNP-BC)
Entity type:Individual
Prefix:MRS
First Name:JUNETTA
Middle Name:A
Last Name:MAYNARD
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:51090 PORTLAND RD
Mailing Address - Street 2:
Mailing Address - City:RACINE
Mailing Address - State:OH
Mailing Address - Zip Code:45771-9706
Mailing Address - Country:US
Mailing Address - Phone:740-843-5368
Mailing Address - Fax:
Practice Address - Street 1:51090 PORTLAND RD
Practice Address - Street 2:
Practice Address - City:RACINE
Practice Address - State:OH
Practice Address - Zip Code:45771-9706
Practice Address - Country:US
Practice Address - Phone:740-843-5368
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-12-12
Last Update Date:2009-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV51731363LF0000X
OHNP-10373363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily