Healthcare Provider Details

I. General information

NPI: 1407907371
Provider Name (Legal Business Name): MAXINE MCGOWAN MSN, PHD, FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/16/2007
Last Update Date: 07/08/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3866 AUGUSTINE PL
REX GA
30273-5822
US

IV. Provider business mailing address

6571 YARBROUGH DR
FAIRBURN GA
30213-4649
US

V. Phone/Fax

Practice location:
  • Phone: 678-343-1257
  • Fax: 770-507-2352
Mailing address:
  • Phone: 678-343-1257
  • Fax: 770-306-8720

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number26NR07760600
License Number StateNJ
# 2
Primary TaxonomyY
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License NumberRN201165
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: