Provider Demographics
NPI:1962742460
Name:MAXWELL, CHARLENE AFABLE (NP)
Entity type:Individual
Prefix:MS
First Name:CHARLENE
Middle Name:AFABLE
Last Name:MAXWELL
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
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Mailing Address - Street 1:421 SW OAK ST
Mailing Address - Street 2:STE. 210
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97204-1817
Mailing Address - Country:US
Mailing Address - Phone:503-988-7468
Mailing Address - Fax:503-988-3015
Practice Address - Street 1:600 NE 8TH ST
Practice Address - Street 2:#300
Practice Address - City:GRESHAM
Practice Address - State:OR
Practice Address - Zip Code:97030-7317
Practice Address - Country:US
Practice Address - Phone:503-988-5155
Practice Address - Fax:509-988-5185
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-20
Last Update Date:2014-08-11
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
OR201391238NP-PP363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR096511Medicaid
OR22959Medicaid
OR096511Medicaid