Provider Demographics
NPI:1386374510
Name:WALLEN LEWIS, MAXINE (RN)
Entity type:Individual
Prefix:
First Name:MAXINE
Middle Name:
Last Name:WALLEN LEWIS
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7831 BIG BUCK DR
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21244-2068
Mailing Address - Country:US
Mailing Address - Phone:443-803-3937
Mailing Address - Fax:
Practice Address - Street 1:7831 BIG BUCK DR
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21244-2068
Practice Address - Country:US
Practice Address - Phone:443-803-3937
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-11
Last Update Date:2022-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD21D2258698247ZC0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247ZC0005XTechnologists, Technicians & Other Technical Service ProvidersTechnician, PathologyClinical Laboratory Director, Non-physician
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD21D22585698Medicaid