Provider Demographics
NPI:1962147660
Name:HINES, MAXINE
Entity type:Individual
Prefix:MISS
First Name:MAXINE
Middle Name:
Last Name:HINES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:619 WASHINGTON DR
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30238-8520
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2363 CLIFTON SPRINGS RD
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30034-2911
Practice Address - Country:US
Practice Address - Phone:404-918-7016
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-28
Last Update Date:2022-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA287680246RP1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes246RP1900XTechnologists, Technicians & Other Technical Service ProvidersTechnician, PathologyPhlebotomyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA22082197Medicaid