Healthcare Provider Details

I. General information

NPI: 1720569858
Provider Name (Legal Business Name): MARCIA ANN MAXWELL
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/27/2018
Last Update Date: 10/20/2021
Certification Date: 10/20/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5057 N 19TH ST
MILWAUKEE WI
53209-5762
US

IV. Provider business mailing address

5057 N 19TH ST
MILWAUKEE WI
53209-5762
US

V. Phone/Fax

Practice location:
  • Phone: 414-716-5971
  • Fax: 414-716-5109
Mailing address:
  • Phone: 414-716-5971
  • Fax: 414-716-5109

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251J00000X
TaxonomyNursing Care Agency
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number323472-31
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: