Provider Demographics
NPI:1487258257
Name:MAYNARD, TERESA SUE
Entity type:Individual
Prefix:
First Name:TERESA
Middle Name:SUE
Last Name:MAYNARD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1444 BIG BRANCH RD
Mailing Address - Street 2:
Mailing Address - City:WAYNE
Mailing Address - State:WV
Mailing Address - Zip Code:25570-9476
Mailing Address - Country:US
Mailing Address - Phone:304-730-3461
Mailing Address - Fax:
Practice Address - Street 1:1444 BIG BRANCH RD
Practice Address - Street 2:
Practice Address - City:WAYNE
Practice Address - State:WV
Practice Address - Zip Code:25570-9476
Practice Address - Country:US
Practice Address - Phone:304-730-3461
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-23
Last Update Date:2020-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant