Basic Information
| Provider Information | |||||||||
| NPI: | 1063559094 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MAYNARD | ||||||||
| FirstName: | ADRIENNE | ||||||||
| MiddleName: | J | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DNP, PMHNP BC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1245 EDGEWATER ST NW | ||||||||
| Address2: | |||||||||
| City: | SALEM | ||||||||
| State: | OR | ||||||||
| PostalCode: | 973044049 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5035885816 | ||||||||
| FaxNumber: | 5035885803 | ||||||||
| Practice Location | |||||||||
| Address1: | 1245 EDGEWATER ST NW | ||||||||
| Address2: | |||||||||
| City: | SALEM | ||||||||
| State: | OR | ||||||||
| PostalCode: | 973044049 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5035885816 | ||||||||
| FaxNumber: | 5035885803 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/31/2007 | ||||||||
| LastUpdateDate: | 11/02/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0808X | 09248 | OH | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health | 363LP0808X | 200850148NP | OR | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health |
No ID Information.