Provider Demographics
NPI:1023045135
Name:MAXWELL, TANYA KAPP (NP)
Entity Type:Individual
Prefix:
First Name:TANYA
Middle Name:KAPP
Last Name:MAXWELL
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1845
Mailing Address - Street 2:
Mailing Address - City:STATESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28687-1845
Mailing Address - Country:US
Mailing Address - Phone:704-873-4277
Mailing Address - Fax:704-873-4511
Practice Address - Street 1:1818 DAVIE AVE
Practice Address - Street 2:
Practice Address - City:STATESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28677-3524
Practice Address - Country:US
Practice Address - Phone:704-873-1036
Practice Address - Fax:704-873-1058
Is Sole Proprietor?:No
Enumeration Date:2006-06-26
Last Update Date:2008-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC900319363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
2806365Medicare PIN
P58324Medicare UPIN