Provider Demographics
NPI:1659797645
Name:MAYNARD-MOISE, EBONY (APRN)
Entity type:Individual
Prefix:MRS
First Name:EBONY
Middle Name:
Last Name:MAYNARD-MOISE
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:MRS
Other - First Name:EBONY
Other - Middle Name:
Other - Last Name:MAYNARD
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:APRN
Mailing Address - Street 1:5200 BABCOCK ST NE STE 301
Mailing Address - Street 2:
Mailing Address - City:PALM BAY
Mailing Address - State:FL
Mailing Address - Zip Code:32905-4648
Mailing Address - Country:US
Mailing Address - Phone:321-541-5547
Mailing Address - Fax:321-766-9396
Practice Address - Street 1:5200 BABCOCK ST NE STE 301
Practice Address - Street 2:
Practice Address - City:PALM BAY
Practice Address - State:FL
Practice Address - Zip Code:32905-4648
Practice Address - Country:US
Practice Address - Phone:321-541-5547
Practice Address - Fax:321-766-9396
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-14
Last Update Date:2024-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11017985363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner