Provider Demographics
NPI:1023377611
Name:HARRIS, MAXINE ROSEMARIE
Entity Type:Individual
Prefix:MISS
First Name:MAXINE
Middle Name:ROSEMARIE
Last Name:HARRIS
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 1:22008 109TH AVE
Mailing Address - Street 2:
Mailing Address - City:QUEENS VILLAGE
Mailing Address - State:NY
Mailing Address - Zip Code:11429-2515
Mailing Address - Country:US
Mailing Address - Phone:917-226-7249
Mailing Address - Fax:
Practice Address - Street 1:220-08 109 AVENUE
Practice Address - Street 2:
Practice Address - City:QUEENS VILLAGE
Practice Address - State:NY
Practice Address - Zip Code:11429
Practice Address - Country:US
Practice Address - Phone:917-226-7249
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-16
Last Update Date:2012-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY460234-1311ZA0620X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYTF7175290OtherNPI