Provider Demographics
NPI:1316297153
Name:MAYNOR, MARY R (RNC-LRN, IBCLC)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:R
Last Name:MAYNOR
Suffix:
Gender:F
Credentials:RNC-LRN, IBCLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:709 GOLFCREST DRIVE
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78239-2623
Mailing Address - Country:US
Mailing Address - Phone:210-650-5510
Mailing Address - Fax:
Practice Address - Street 1:709 GOLFCREST DR
Practice Address - Street 2:
Practice Address - City:WINDCREST
Practice Address - State:TX
Practice Address - Zip Code:78239-2623
Practice Address - Country:US
Practice Address - Phone:210-650-5510
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-09-19
Last Update Date:2012-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX737276163W00000X
TXIBCLC # 11117120163WL0100X
TXC-LRN #VSHA4A4004B163WN0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No163WL0100XNursing Service ProvidersRegistered NurseLactation Consultant
No163WN0003XNursing Service ProvidersRegistered NurseNeonatal, Low-Risk