Provider Demographics
NPI:1518789437
Name:MAYNARD, DIANA DORIS (LMT)
Entity type:Individual
Prefix:
First Name:DIANA
Middle Name:DORIS
Last Name:MAYNARD
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:205 S BC AVE STE 117
Mailing Address - Street 2:
Mailing Address - City:LYNDEN
Mailing Address - State:WA
Mailing Address - Zip Code:98264-2053
Mailing Address - Country:US
Mailing Address - Phone:707-397-5592
Mailing Address - Fax:
Practice Address - Street 1:1112 FINNEGAN WAY
Practice Address - Street 2:
Practice Address - City:BELLINGHAM
Practice Address - State:WA
Practice Address - Zip Code:98225-6622
Practice Address - Country:US
Practice Address - Phone:360-527-9566
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-30
Last Update Date:2024-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA61610015225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist