=====================================================
General NPI Number Information
=====================================================
NPI Number | 1427523331
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SUZANNAH MAYNARD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/06/2018
-----------------------------------------------------
Last Update Date | 03/17/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 760 CARPENTER LN
-----------------------------------------------------
City | PHILADELPHIA
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19119-3406
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 215-848-6880
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 131 E PALMER AVE
-----------------------------------------------------
City | COLLINGSWOOD
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08108-1222
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 215-530-4979
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363L00000X
-----------------------------------------------------
Taxonomy Name | Nurse Practitioner
-----------------------------------------------------
License Number | 26NJ00893400
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363L00000X
-----------------------------------------------------
Taxonomy Name | Nurse Practitioner
-----------------------------------------------------
License Number | SP018890
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------