Provider Demographics
NPI:1467006577
Name:MAXWELL, TORBERTHA PANNOR (FNP-C)
Entity Type:Individual
Prefix:
First Name:TORBERTHA
Middle Name:PANNOR
Last Name:MAXWELL
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:TORBERTHA
Other - Middle Name:PANNOR
Other - Last Name:TORBON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP-C
Mailing Address - Street 1:8601 LINCOLN BLVD APT 3412
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90045-7604
Mailing Address - Country:US
Mailing Address - Phone:831-406-0463
Mailing Address - Fax:
Practice Address - Street 1:4650 LINCOLN BLVD
Practice Address - Street 2:
Practice Address - City:MARINA DEL REY
Practice Address - State:CA
Practice Address - Zip Code:90292-6306
Practice Address - Country:US
Practice Address - Phone:310-823-8911
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-26
Last Update Date:2022-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAF04190241363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily