Basic Information
| Provider Information | |||||||||
| NPI: | 1619420957 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SUZANNE MAYNARD, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 112 | ||||||||
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| City: | MUNCIE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 473080112 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7652840493 | ||||||||
| FaxNumber: | 7652842434 | ||||||||
| Practice Location | |||||||||
| Address1: | 111 W 16TH AVE | ||||||||
| Address2: | UNIT 203 | ||||||||
| City: | ANCHORAGE | ||||||||
| State: | AK | ||||||||
| PostalCode: | 995015169 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9075611430 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/03/2016 | ||||||||
| LastUpdateDate: | 08/03/2016 | ||||||||
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| AuthorizedOfficialLastName: | MAYNARD | ||||||||
| AuthorizedOfficialFirstName: | SUZANNE | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER/CRNA | ||||||||
| AuthorizedOfficialTelephone: | 6038330635 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | CRNA | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | NURA373 | AK | Y | 193400000X SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
No ID Information.