Provider Demographics
NPI:1427208305
Name:MAXWELL, STACY M
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:M
Last Name:MAXWELL
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 1:3201 N 3RD ST
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85012-2631
Mailing Address - Country:US
Mailing Address - Phone:602-265-1774
Mailing Address - Fax:602-265-1738
Practice Address - Street 1:3201 N 3RD ST
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85012-2631
Practice Address - Country:US
Practice Address - Phone:602-265-1774
Practice Address - Fax:602-265-1738
Is Sole Proprietor?:No
Enumeration Date:2008-09-26
Last Update Date:2008-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist