Healthcare Provider Details

I. General information

NPI: 1730323072
Provider Name (Legal Business Name): MISS LILLIE MARIA MAXWELL
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/30/2009
Last Update Date: 01/17/2026
Certification Date: 01/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4963 DONOVAN DR
GARFIELD HTS OH
44125-2049
US

IV. Provider business mailing address

4963 DONOVAN DR
GARFIELD HTS OH
44125-2049
US

V. Phone/Fax

Practice location:
  • Phone: 254-338-8436
  • Fax:
Mailing address:
  • Phone: 254-338-8436
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number196440
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code164X00000X
TaxonomyLicensed Vocational Nurse
License Number196440
License Number StateTX
# 3
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: