MEDICARE: VINESSA MAXWELL PMHNP-BC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163W00000X	Registered Nurse	726066	NY
2	163WP0807X	Child & Adolescent Psychiatric/Mental Health Registered Nurse	726066	NY
3	163WP0808X	Psychiatric/Mental Health Registered Nurse	726066	NY
4	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	F402910	NY

General Provider Information

NPI Number	:	1881214377
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	VINESSA MAXWELL PMHNP-BC

Provider Business Mailing Address
First Line	:	920 CO OP CITY BLVD APT 14D
Second Line	:
City	:	BRONX
State	:	NY
Zip	:	10475-1634
Country	:	US
Telephone Number	:	347-697-3037
Fax Number	:

Provider Business Practice Location Address
First Line	:	920 CO OP CITY BLVD APT 14D
Second Line	:
City	:	BRONX
State	:	NY
Zip	:	10475-1634
Country	:	US
Telephone Number	:	347-697-3037
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/24/2020
Last Update Date	:	04/07/2021

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