Healthcare Provider Details

I. General information

NPI: 1316297153
Provider Name (Legal Business Name): MARY R MAYNOR RNC-LRN, IBCLC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/19/2012
Last Update Date: 09/19/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

709 GOLFCREST DR
WINDCREST TX
78239-2623
US

IV. Provider business mailing address

709 GOLFCREST DRIVE
SAN ANTONIO TX
78239-2623
US

V. Phone/Fax

Practice location:
  • Phone: 210-650-5510
  • Fax:
Mailing address:
  • Phone: 210-650-5510
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number737276
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code163WL0100X
TaxonomyLactation Consultant (Registered Nurse)
License NumberIBCLC # 11117120
License Number StateTX
# 3
Primary TaxonomyN
Taxonomy Code163WN0003X
TaxonomyLow-Risk Neonatal Registered Nurse
License NumberC-LRN #VSHA4A4004B
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: