Healthcare Provider Details

I. General information

NPI: 1477040491
Provider Name (Legal Business Name): MARISA MAXWELL RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/16/2018
Last Update Date: 04/16/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18218 NORTH RD
BOTHELL WA
98012-6265
US

IV. Provider business mailing address

20420 68TH AVE W
LYNNWOOD WA
98036-7400
US

V. Phone/Fax

Practice location:
  • Phone: 425-431-7520
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WS0200X
TaxonomySchool Registered Nurse
License Number60815112
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: