MEDICARE: MARCIA ANN MAXWELL

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	164W00000X	Licensed Practical Nurse	323472-31	WI
2	251J00000X	Nursing Care Agency
3	310400000X	Assisted Living Facility

General Provider Information

NPI Number	:	1720569858
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARCIA ANN MAXWELL

Provider Business Mailing Address
First Line	:	5057 N 19TH ST
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53209-5762
Country	:	US
Telephone Number	:	414-716-5971
Fax Number	:	414-716-5109

Provider Business Practice Location Address
First Line	:	5057 N 19TH ST
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53209-5762
Country	:	US
Telephone Number	:	414-716-5971
Fax Number	:	414-716-5109

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/27/2018
Last Update Date	:	10/20/2021

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Directions to “ MARCIA ANN MAXWELL ” Practice Location

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