Healthcare Provider Details

I. General information

NPI: 1447644166
Provider Name (Legal Business Name): CALLIE MAYNARD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/19/2015
Last Update Date: 03/19/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

901 S NATIONAL AVE
SPRINGFIELD MO
65897-0027
US

IV. Provider business mailing address

901 S NATIONAL AVE
SPRINGFIELD MO
65897-0027
US

V. Phone/Fax

Practice location:
  • Phone: 417-836-5667
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: