MEDICARE: MARILYN P MAXWELL LPN

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	306153-031	WI

General Provider Information

NPI Number	:	1831465327
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARILYN P MAXWELL LPN

Provider Business Mailing Address
First Line	:	3411 N 1ST ST
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53212-1528
Country	:	US
Telephone Number	:	414-698-3127
Fax Number	:

Provider Business Practice Location Address
First Line	:	3411 N 1ST ST
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53212-1528
Country	:	US
Telephone Number	:	414-698-3127
Fax Number	:

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

Provider Enumeration Date	:	03/28/2012
Last Update Date	:	03/28/2012

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