Healthcare Provider Details

I. General information

NPI: 1275400624
Provider Name (Legal Business Name): MAXWELL LENNON LANGENSTEIN RN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/21/2025
Last Update Date: 04/15/2026
Certification Date: 10/21/2025
Deactivation Date: 10/23/2025
Reactivation Date: 04/15/2026

III. Provider practice location address

516 E NIZHONI BLVD
GALLUP NM
87301-5748
US

IV. Provider business mailing address

209 NICOLE LN
BERKELEY SPRINGS WV
25411-4841
US

V. Phone/Fax

Practice location:
  • Phone: 505-726-8549
  • Fax:
Mailing address:
  • Phone: 304-707-1972
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number98312
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: