Healthcare Provider Details

I. General information

NPI: 1942618657
Provider Name (Legal Business Name): TIMOTHY MAYNARD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/25/2014
Last Update Date: 02/20/2020
Certification Date: 02/20/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

402 C STREET
CEREDO WV
25507
US

IV. Provider business mailing address

PO BOX 4100
BARBOURSVILLE WV
25504-4100
US

V. Phone/Fax

Practice location:
  • Phone: 304-908-1204
  • Fax: 304-908-1224
Mailing address:
  • Phone: 304-908-1204
  • Fax: 304-908-1224

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number3008802
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: