Healthcare Provider Details

I. General information

NPI: 1578171013
Provider Name (Legal Business Name): NICOLE MAYNOR
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/21/2020
Last Update Date: 08/17/2020
Certification Date: 08/17/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 AVENUE C STE 110
MADISON WV
25130-1100
US

IV. Provider business mailing address

1 AVENUE C STE 102
MADISON WV
25130-1100
US

V. Phone/Fax

Practice location:
  • Phone: 304-369-6400
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3747P1801X
TaxonomyPersonal Care Attendant
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: