Provider Demographics
NPI:1649783754
Name:KING, MAXINE MILLICENT (NP-C)
Entity type:Individual
Prefix:
First Name:MAXINE
Middle Name:MILLICENT
Last Name:KING
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 RIVER DR
Mailing Address - Street 2:
Mailing Address - City:FORT BRAGG
Mailing Address - State:CA
Mailing Address - Zip Code:95437-5403
Mailing Address - Country:US
Mailing Address - Phone:707-961-4922
Mailing Address - Fax:707-961-4921
Practice Address - Street 1:291 STONER AVE
Practice Address - Street 2:
Practice Address - City:WESTMINSTER
Practice Address - State:MD
Practice Address - Zip Code:21157-5647
Practice Address - Country:US
Practice Address - Phone:410-871-6400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-11-10
Last Update Date:2025-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDAC003700363LG0600X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NVAPRN002718OtherSTATE LICENSE