Healthcare Provider Details

I. General information

NPI: 1487749636
Provider Name (Legal Business Name): MARY E MAXWELL NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/04/2006
Last Update Date: 09/04/2020
Certification Date: 09/04/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1445 PORTLAND AVE PARNELL OFFICE BLDG, STE 304
ROCHESTER NY
14621-3036
US

IV. Provider business mailing address

100 KINGS HWY S
ROCHESTER NY
14617-5504
US

V. Phone/Fax

Practice location:
  • Phone: 585-342-7170
  • Fax: 585-342-5855
Mailing address:
  • Phone: 585-342-7170
  • Fax: 585-342-5855

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number301455
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: