Healthcare Provider Details

I. General information

NPI: 1962742460
Provider Name (Legal Business Name): CHARLENE AFABLE MAXWELL NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/20/2013
Last Update Date: 08/11/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 NE 8TH ST #300
GRESHAM OR
97030-7317
US

IV. Provider business mailing address

421 SW OAK ST STE. 210
PORTLAND OR
97204-1817
US

V. Phone/Fax

Practice location:
  • Phone: 503-988-5155
  • Fax: 509-988-5185
Mailing address:
  • Phone: 503-988-7468
  • Fax: 503-988-3015

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number201391238NP-PP
License Number StateOR

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier096511
Identifier TypeMEDICAID
Identifier StateOR
Identifier Issuer
# 2
Identifier22959
Identifier TypeMEDICAID
Identifier StateOR
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: