Healthcare Provider Details

I. General information

NPI: 1295567477
Provider Name (Legal Business Name): MYLES D MAXWELL RN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/16/2024
Last Update Date: 07/07/2026
Certification Date: 07/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1585 N HAVEN DR
PALATINE IL
60074-2425
US

IV. Provider business mailing address

1585 N HAVEN DR
PALATINE IL
60074-2425
US

V. Phone/Fax

Practice location:
  • Phone: 608-774-6509
  • Fax:
Mailing address:
  • Phone: 608-774-6509
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number260639-30
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License Number260639
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: