Healthcare Provider Details

I. General information

NPI: 1316632763
Provider Name (Legal Business Name): NICOLE MAXWELL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/10/2023
Last Update Date: 05/23/2023
Certification Date: 05/23/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1529 E PALMDALE BLVD STE 330
PALMDALE CA
93550-2030
US

IV. Provider business mailing address

2330 E AVENUE J8 SPC 58
LANCASTER CA
93535-5672
US

V. Phone/Fax

Practice location:
  • Phone: 661-575-1800
  • Fax:
Mailing address:
  • Phone: 310-803-0896
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: