Provider Demographics
NPI:1679308126
Name:MAYNARD, MACKINLIE (RN)
Entity type:Individual
Prefix:
First Name:MACKINLIE
Middle Name:
Last Name:MAYNARD
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:615 S PALATINE HILL RD
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97219-8091
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:615 S PALATINE HILL RD
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97219-8091
Practice Address - Country:US
Practice Address - Phone:503-768-7165
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-04
Last Update Date:2024-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR202103350RN163WC1400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC1400XNursing Service ProvidersRegistered NurseCollege Health