Provider Demographics
NPI:1083772065
Name:MAXWELL, NICOLE MARIE (NMD)
Entity Type:Individual
Prefix:DR
First Name:NICOLE
Middle Name:MARIE
Last Name:MAXWELL
Suffix:
Gender:F
Credentials:NMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4219 W EMERALD ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83706-2036
Mailing Address - Country:US
Mailing Address - Phone:208-338-0405
Mailing Address - Fax:208-422-9957
Practice Address - Street 1:4219 W EMERALD ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83706-2036
Practice Address - Country:US
Practice Address - Phone:208-338-0405
Practice Address - Fax:208-422-9957
Is Sole Proprietor?:No
Enumeration Date:2006-12-04
Last Update Date:2020-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WANT00001153175F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175F00000XOther Service ProvidersNaturopath
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA201450836OtherTAX IDENTIFICATION NUMBER
WA453328671OtherTIN