Provider Demographics
NPI:1295547230
Name:MAYNARD, GABRIELLE (NP)
Entity type:Individual
Prefix:
First Name:GABRIELLE
Middle Name:
Last Name:MAYNARD
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4450 GIBSON AVE # 1F
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63110-1614
Mailing Address - Country:US
Mailing Address - Phone:304-380-3386
Mailing Address - Fax:
Practice Address - Street 1:3309 S KINGSHIGHWAY BLVD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63139-1101
Practice Address - Country:US
Practice Address - Phone:314-206-3700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-01-27
Last Update Date:2025-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2025001670363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health