Healthcare Provider Details

I. General information

NPI: 1407669203
Provider Name (Legal Business Name): CLAY D MAXSON RN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/28/2025
Last Update Date: 01/28/2025
Certification Date: 01/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1907 W SYCAMORE ST
KOKOMO IN
46901-5148
US

IV. Provider business mailing address

216 PROMISE LN APT 303
LAFAYETTE IN
47905-5052
US

V. Phone/Fax

Practice location:
  • Phone: 765-452-5611
  • Fax:
Mailing address:
  • Phone: 765-490-1147
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number28245948C
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code163WE0003X
TaxonomyEmergency Registered Nurse
License Number28245948A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: