Healthcare Provider Details

I. General information

NPI: 1881214377
Provider Name (Legal Business Name): VINESSA MAXWELL PMHNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/24/2020
Last Update Date: 04/07/2021
Certification Date: 04/07/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

920 CO OP CITY BLVD APT 14D
BRONX NY
10475-1634
US

IV. Provider business mailing address

920 CO OP CITY BLVD APT 14D
BRONX NY
10475-1634
US

V. Phone/Fax

Practice location:
  • Phone: 347-697-3037
  • Fax:
Mailing address:
  • Phone: 347-697-3037
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number726066
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code163WP0807X
TaxonomyChild & Adolescent Psychiatric/Mental Health Registered Nurse
License Number726066
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number726066
License Number StateNY
# 4
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberF402910
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: