Basic Information
| Provider Information | |||||||||
| NPI: | 1689897886 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MAYNARD | ||||||||
| FirstName: | JAMILEY | ||||||||
| MiddleName: | C | ||||||||
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| Credential: | FNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2723 S 7TH ST | ||||||||
| Address2: | SUITE A | ||||||||
| City: | TERRE HAUTE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 478023558 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8122381730 | ||||||||
| FaxNumber: | 8122421565 | ||||||||
| Practice Location | |||||||||
| Address1: | 2723 S 7TH STREET | ||||||||
| Address2: | SUITE C | ||||||||
| City: | TERRE HAUTE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 478023558 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8122325936 | ||||||||
| FaxNumber: | 8122351290 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/10/2007 | ||||||||
| LastUpdateDate: | 07/15/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 71001096A | IN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 200822620 | 05 | IN | MEDICAID |