Healthcare Provider Details

I. General information

NPI: 1063111672
Provider Name (Legal Business Name): DIANE MAXWELL NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/02/2023
Last Update Date: 01/16/2025
Certification Date: 01/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1385 S HIGHLAND AVE STE B1
JACKSON TN
38301-7547
US

IV. Provider business mailing address

1385 S HIGHLAND AVE STE B1
JACKSON TN
38301-7547
US

V. Phone/Fax

Practice location:
  • Phone: 731-427-0470
  • Fax: 731-427-0995
Mailing address:
  • Phone: 731-427-0470
  • Fax: 731-427-0995

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number0000243667
License Number StateTN
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberAPN0000036026
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: