Healthcare Provider Details

I. General information

NPI: 1518481308
Provider Name (Legal Business Name): TYLER LEIGH MAYNARD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: TYLER SHUMARD

II. Dates (important events)

Enumeration Date: 08/02/2017
Last Update Date: 01/09/2023
Certification Date: 01/09/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

908 N REYNOLDS RD
BRYANT AR
72022-3034
US

IV. Provider business mailing address

PO DRAWER 2109
RUSSELLVILLE AR
72811
US

V. Phone/Fax

Practice location:
  • Phone: 501-847-9711
  • Fax:
Mailing address:
  • Phone: 479-967-2322
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number4232
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: