Provider Demographics
NPI:1275706939
Name:MAX, HANEELIA JEAN
Entity Type:Individual
Prefix:MRS
First Name:HANEELIA
Middle Name:JEAN
Last Name:MAX
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:PO BOX 2489
Mailing Address - Street 2:
Mailing Address - City:TUBA CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:86045-2489
Mailing Address - Country:US
Mailing Address - Phone:928-283-5206
Mailing Address - Fax:928-283-5733
Practice Address - Street 1:322 HWY 160
Practice Address - Street 2:SUITE #13
Practice Address - City:TUBA CITY
Practice Address - State:AZ
Practice Address - Zip Code:86045-2489
Practice Address - Country:US
Practice Address - Phone:928-283-5206
Practice Address - Fax:928-283-5733
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-02
Last Update Date:2008-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156F00000XEye and Vision Services ProvidersTechnician/Technologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ119596Medicaid