Provider Demographics
NPI:1992413124
Name:MAYNE-FARAH, JENNIFER (APRN, FNP-C)
Entity type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:
Last Name:MAYNE-FARAH
Suffix:
Gender:F
Credentials:APRN, FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6204 SEA MEADOW DR
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76132-1114
Mailing Address - Country:US
Mailing Address - Phone:817-475-9791
Mailing Address - Fax:
Practice Address - Street 1:1759 BROAD PARK CIR S
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:TX
Practice Address - Zip Code:76063-7833
Practice Address - Country:US
Practice Address - Phone:682-341-3910
Practice Address - Fax:682-400-1288
Is Sole Proprietor?:No
Enumeration Date:2022-11-07
Last Update Date:2022-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1084100363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily