Healthcare Provider Details

I. General information

NPI: 1578277182
Provider Name (Legal Business Name): ALYSSA GRACE MAYNOR M.ED. CF-SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

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

III. Provider practice location address

3663 CROWN POINT CT
JACKSONVILLE FL
32257-5967
US

IV. Provider business mailing address

3663 CROWN POINT CT
JACKSONVILLE FL
32257-5967
US

V. Phone/Fax

Practice location:
  • Phone: 904-288-8910
  • Fax: 904-288-8912
Mailing address:
  • Phone: 904-288-8910
  • Fax: 904-288-8912

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberSZ11140
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: