Healthcare Provider Details

I. General information

NPI: 1659797645
Provider Name (Legal Business Name): EBONY L MAYNARD APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: EBONY L MAYNARD APRN

II. Dates (important events)

Enumeration Date: 03/14/2014
Last Update Date: 07/02/2026
Certification Date: 07/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5200 BABCOCK ST NE STE 301
PALM BAY FL
32905-4648
US

IV. Provider business mailing address

5200 BABCOCK ST NE STE 301
PALM BAY FL
32905-4648
US

V. Phone/Fax

Practice location:
  • Phone: 321-541-5547
  • Fax: 321-766-9396
Mailing address:
  • Phone: 321-541-5547
  • Fax: 321-766-9396

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberAPRN11017985
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN11017985
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: