Provider Demographics
NPI:1407075484
Name:MAXWELL, AMIE NICOLE (LPTA)
Entity Type:Individual
Prefix:MR
First Name:AMIE
Middle Name:NICOLE
Last Name:MAXWELL
Suffix:
Gender:F
Credentials:LPTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:765 AGNES LN NW
Mailing Address - Street 2:
Mailing Address - City:WILLIS
Mailing Address - State:VA
Mailing Address - Zip Code:24380-4600
Mailing Address - Country:US
Mailing Address - Phone:540-789-8090
Mailing Address - Fax:
Practice Address - Street 1:650 N JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24016-1427
Practice Address - Country:US
Practice Address - Phone:540-343-3484
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2306001726225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant