Healthcare Provider Details

I. General information

NPI: 1609498872
Provider Name (Legal Business Name): SHIRLEY MAXWELL
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/11/2020
Last Update Date: 05/11/2020
Certification Date: 05/11/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1106 LITTLE FOX DR
DALLAS TX
75253-5077
US

IV. Provider business mailing address

1106 LITTLE FOX DR
DALLAS TX
75253-5077
US

V. Phone/Fax

Practice location:
  • Phone: 214-641-8507
  • Fax:
Mailing address:
  • Phone: 214-641-8507
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code347C00000X
TaxonomyPrivate Vehicle
License Number22341179
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: