Provider Demographics
NPI:1124671961
Name:MAYNARD, SAMUEL BENEDICT (APRN)
Entity type:Individual
Prefix:
First Name:SAMUEL
Middle Name:BENEDICT
Last Name:MAYNARD
Suffix:
Gender:M
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:749 9TH ST UNIT 203
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27705-1060
Mailing Address - Country:US
Mailing Address - Phone:504-432-5708
Mailing Address - Fax:
Practice Address - Street 1:1 SHAWS CV
Practice Address - Street 2:
Practice Address - City:NEW LONDON
Practice Address - State:CT
Practice Address - Zip Code:06320-4902
Practice Address - Country:US
Practice Address - Phone:860-447-8304
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-22
Last Update Date:2019-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT162343163W00000X
CT8305363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse