Provider Demographics
NPI:1104349919
Name:MAXWELL, LAURYN ASHLEY (PT, DPT)
Entity type:Individual
Prefix:
First Name:LAURYN
Middle Name:ASHLEY
Last Name:MAXWELL
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:LAURYN
Other - Middle Name:ASHLEY
Other - Last Name:HANNA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT, DPT
Mailing Address - Street 1:2224 E CEDAR AVE STE 1
Mailing Address - Street 2:
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86004-1957
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2224 E CEDAR AVE STE 1
Practice Address - Street 2:
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86004-1957
Practice Address - Country:US
Practice Address - Phone:928-779-1679
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-24
Last Update Date:2018-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ13039225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist