Healthcare Provider Details

I. General information

NPI: 1619420957
Provider Name (Legal Business Name): SUZANNE MAYNARD, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/03/2016
Last Update Date: 08/03/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 W 16TH AVE UNIT 203
ANCHORAGE AK
99501-5169
US

IV. Provider business mailing address

PO BOX 112
MUNCIE IN
47308-0112
US

V. Phone/Fax

Practice location:
  • Phone: 907-561-1430
  • Fax:
Mailing address:
  • Phone: 765-284-0493
  • Fax: 765-284-2434

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberNURA373
License Number StateAK

VIII. Authorized Official

Name: SUZANNE MAYNARD
Title or Position: OWNER/CRNA
Credential: CRNA
Phone: 603-833-0635