Healthcare Provider Details

I. General information

NPI: 1881460509
Provider Name (Legal Business Name): PRISCILLA MAXWELL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: PRISCILLA MAXWELL REGISTERED NURSE

II. Dates (important events)

Enumeration Date: 12/04/2023
Last Update Date: 10/01/2025
Certification Date: 10/01/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

320 LANIER AVE W STE 200
FAYETTEVILLE GA
30214-7443
US

IV. Provider business mailing address

320 LANIER AVE W STE 200
FAYETTEVILLE GA
30214-7443
US

V. Phone/Fax

Practice location:
  • Phone: 470-516-4399
  • Fax: 470-516-4399
Mailing address:
  • Phone: 470-516-4399
  • Fax: 470-516-4399

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN288759
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code163WP0807X
TaxonomyChild & Adolescent Psychiatric/Mental Health Registered Nurse
License NumberRN288759
License Number StateGA
# 3
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberRN288759
License Number StateGA
# 4
Primary TaxonomyN
Taxonomy Code163WP0809X
TaxonomyAdult Psychiatric/Mental Health Registered Nurse
License NumberRN288759
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: