Provider Demographics
NPI:1962198432
Name:MAXEY, TIBETT SHANTI
Entity type:Individual
Prefix:
First Name:TIBETT
Middle Name:SHANTI
Last Name:MAXEY
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 1:61 GREENLEAF MDWS
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14612-4335
Mailing Address - Country:US
Mailing Address - Phone:585-200-0168
Mailing Address - Fax:
Practice Address - Street 1:61 GREENLEAF MDWS
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14612-4335
Practice Address - Country:US
Practice Address - Phone:585-200-0168
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-17
Last Update Date:2023-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY812156-01163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse