Provider Demographics
NPI:1669658597
Name:MAXWELL, NADINE SOPHIA (RN)
Entity Type:Individual
Prefix:MS
First Name:NADINE
Middle Name:SOPHIA
Last Name:MAXWELL
Suffix:
Gender:F
Credentials:RN
Other - Prefix:MISS
Other - First Name:NADINE
Other - Middle Name:SOPHIA
Other - Last Name:BROWN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:294 PLYMOUTH CT
Mailing Address - Street 2:
Mailing Address - City:UNIONDALE
Mailing Address - State:NY
Mailing Address - Zip Code:11553-1929
Mailing Address - Country:US
Mailing Address - Phone:516-833-6620
Mailing Address - Fax:
Practice Address - Street 1:294 PLYMOUTH CT
Practice Address - Street 2:
Practice Address - City:UNIONDALE
Practice Address - State:NY
Practice Address - Zip Code:11553-1929
Practice Address - Country:US
Practice Address - Phone:516-833-6620
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-09
Last Update Date:2008-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY584354163W00000X, 163WC1500X, 372600000X
NY248102164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No163WC1500XNursing Service ProvidersRegistered NurseCommunity Health
No164W00000XNursing Service ProvidersLicensed Practical Nurse
No372600000XNursing Service Related ProvidersAdult Companion
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02758836Medicaid