Provider Demographics
NPI:1104970441
Name:MITCHELL, MAXINE (NP)
Entity type:Individual
Prefix:
First Name:MAXINE
Middle Name:
Last Name:MITCHELL
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:MAXINE
Other - Middle Name:
Other - Last Name:MCCLINTON-WILSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:519 STEPHENSON AVE
Mailing Address - Street 2:
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31405-5969
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:340 EISENHOWER DR
Practice Address - Street 2:1500
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31406-1600
Practice Address - Country:US
Practice Address - Phone:912-354-9447
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-23
Last Update Date:2016-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041-235446364SA2200X
GARN246516363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No364SA2200XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL041-235446OtherSTATE LICENSE