Healthcare Provider Details

I. General information

NPI: 1871112110
Provider Name (Legal Business Name): LORIE MAXWELL STARTUP NP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SUSAN LORIE MAXWELL

II. Dates (important events)

Enumeration Date: 04/15/2020
Last Update Date: 01/28/2022
Certification Date: 01/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

129 BANKHEAD HWY
CARROLLTON GA
30117-3425
US

IV. Provider business mailing address

129 BANKHEAD HWY
CARROLLTON GA
30117-3425
US

V. Phone/Fax

Practice location:
  • Phone: 770-838-8440
  • Fax:
Mailing address:
  • Phone: 770-838-8440
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WS0200X
TaxonomySchool Registered Nurse
License Number098171
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN098171
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: