Provider Demographics
NPI:1699131003
Name:MAXEY, TYVONISE (PLN)
Entity type:Individual
Prefix:
First Name:TYVONISE
Middle Name:
Last Name:MAXEY
Suffix:
Gender:F
Credentials:PLN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16 FLOYD DR
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14623-4712
Mailing Address - Country:US
Mailing Address - Phone:585-479-0715
Mailing Address - Fax:
Practice Address - Street 1:16 FLOYD DR
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14623-4712
Practice Address - Country:US
Practice Address - Phone:585-479-0715
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-14
Last Update Date:2016-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY10324258164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse