=====================================================
General NPI Number Information
=====================================================
NPI Number | 1306893920
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LAURIE L. MAXWELL NP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/28/2006
-----------------------------------------------------
Last Update Date | 03/18/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3431 LAKEWOOD DR
-----------------------------------------------------
City | WEST MELBOURNE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32904-5206
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 321-373-1226
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 633819
-----------------------------------------------------
City | CINCINNATI
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45263-0001
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 865-292-3000
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363L00000X
-----------------------------------------------------
Taxonomy Name | Nurse Practitioner
-----------------------------------------------------
License Number | APN5448
-----------------------------------------------------
License Number State | TN
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | 9240703
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------