1215582945 NPI number — MRS. LAUREN WALL MAYNARD CRNP

Table of content: MRS. LAUREN WALL MAYNARD CRNP (NPI 1215582945)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1215582945 NPI number — MRS. LAUREN WALL MAYNARD CRNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MAYNARD
Provider First Name:
LAUREN
Provider Middle Name:
WALL
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
CRNP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1215582945
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/08/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
845 SHADES CREST RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BIRMINGHAM
Provider Business Mailing Address State Name:
AL
Provider Business Mailing Address Postal Code:
35226-1901
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
205-516-5602
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2145 HIGHLAND AVE S STE 200
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BIRMINGHAM
Provider Business Practice Location Address State Name:
AL
Provider Business Practice Location Address Postal Code:
35205-4015
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
205-933-0230
Provider Business Practice Location Address Fax Number:
205-933-6400
Provider Enumeration Date:
08/08/2019

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LF0000X , with the licence number:  1-150293 , registered in the state of AL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)