Provider Demographics
NPI:1528270501
Name:MAXWELL, MICHELLE LYNN (RN)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:LYNN
Last Name:MAXWELL
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 1:9121 W BROAD ST
Mailing Address - Street 2:
Mailing Address - City:GALLOWAY
Mailing Address - State:OH
Mailing Address - Zip Code:43119-9606
Mailing Address - Country:US
Mailing Address - Phone:614-879-4019
Mailing Address - Fax:
Practice Address - Street 1:9121 W BROAD ST
Practice Address - Street 2:
Practice Address - City:GALLOWAY
Practice Address - State:OH
Practice Address - Zip Code:43119-9606
Practice Address - Country:US
Practice Address - Phone:614-879-4019
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-04
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRN-251082163WE0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WE0003XNursing Service ProvidersRegistered NurseEmergency
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2137226Medicaid