Healthcare Provider Details

I. General information

NPI: 1609396746
Provider Name (Legal Business Name): MAGGIE MICHELE SEXTON FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/20/2017
Last Update Date: 06/20/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2311 NW NORTHRUP ST STE 100
PORTLAND OR
97210-2912
US

IV. Provider business mailing address

5011 SE TIBBETTS ST
PORTLAND OR
97206-2133
US

V. Phone/Fax

Practice location:
  • Phone: 816-803-2882
  • Fax:
Mailing address:
  • Phone: 816-803-2882
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number201702577NP-PP
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: