Provider Demographics
NPI:1558394304
Name:RACHELLE, MAXINE R (PA)
Entity Type:Individual
Prefix:MS
First Name:MAXINE
Middle Name:R
Last Name:RACHELLE
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:130 TAMIAMI TRL N
Mailing Address - Street 2:#220
Mailing Address - City:NAPLES
Mailing Address - State:FL
Mailing Address - Zip Code:34102-6224
Mailing Address - Country:US
Mailing Address - Phone:239-624-1700
Mailing Address - Fax:239-434-8605
Practice Address - Street 1:130 TAMIAMI TRL N
Practice Address - Street 2:#220
Practice Address - City:NAPLES
Practice Address - State:FL
Practice Address - Zip Code:34102-6224
Practice Address - Country:US
Practice Address - Phone:239-624-1700
Practice Address - Fax:239-434-8605
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2020-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9106472363AS0400X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLHY592YOtherMEDICARE
NY02676873Medicaid
FL010616700Medicaid
FLY0L7HOtherBCBS
FLHT592YMedicare PIN
FLHY592YOtherMEDICARE