1942817689 NPI number — BRENNA GRACE MAYNARD-WHITE NP

Table of content: BRENNA GRACE MAYNARD-WHITE NP (NPI 1942817689)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1942817689 NPI number — BRENNA GRACE MAYNARD-WHITE NP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MAYNARD-WHITE
Provider First Name:
BRENNA
Provider Middle Name:
GRACE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
NP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
MAYNARD
Provider Other First Name:
BRENNA
Provider Other Middle Name:
GRACE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
NP
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1942817689
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/10/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
87 FATIMA DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BRISTOL
Provider Business Mailing Address State Name:
RI
Provider Business Mailing Address Postal Code:
02809-4738
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
401-575-9974
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
277 PLEASANT ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FALL RIVER
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
02721-3005
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
508-676-3292
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/27/2020

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:  RN2308899 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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