=====================================================
General NPI Number Information
=====================================================
NPI Number | 1720311277
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MAXINE ANDREA NEWELL PT, DRPH
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/16/2009
-----------------------------------------------------
Last Update Date | 09/16/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 16320 ORICK AVE AOT 7
-----------------------------------------------------
City | VICTORVILLE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92394-1192
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 951-859-5892
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 16320 ORICK AVE AOT 7
-----------------------------------------------------
City | VICTORVILLE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92394-1192
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 951-859-5892
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2251G0304X
-----------------------------------------------------
Taxonomy Name | Geriatric Physical Therapist
-----------------------------------------------------
License Number | PT28650
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------