Provider Demographics
NPI:1639769847
Name:MAXWELL, HALEY C (PA)
Entity Type:Individual
Prefix:
First Name:HALEY
Middle Name:C
Last Name:MAXWELL
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 1:2902 59TH ST W STE C
Mailing Address - Street 2:
Mailing Address - City:BRADENTON
Mailing Address - State:FL
Mailing Address - Zip Code:34209-7021
Mailing Address - Country:US
Mailing Address - Phone:941-877-7000
Mailing Address - Fax:941-242-1440
Practice Address - Street 1:2902 59TH ST W STE C
Practice Address - Street 2:
Practice Address - City:BRADENTON
Practice Address - State:FL
Practice Address - Zip Code:34209-7021
Practice Address - Country:US
Practice Address - Phone:941-877-7000
Practice Address - Fax:941-242-1440
Is Sole Proprietor?:No
Enumeration Date:2021-01-21
Last Update Date:2022-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9113981101Y00000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPA9113981OtherPA LICENCE