Provider Demographics
NPI:1639839376
Name:MAXON, TYRELLE
Entity Type:Individual
Prefix:
First Name:TYRELLE
Middle Name:
Last Name:MAXON
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 1:13642 HOUSE OF LANCASTER DR
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70816-1119
Mailing Address - Country:US
Mailing Address - Phone:225-803-8073
Mailing Address - Fax:
Practice Address - Street 1:13642 HOUSE OF LANCASTER DR
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70816-1119
Practice Address - Country:US
Practice Address - Phone:225-803-8073
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-21
Last Update Date:2021-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care