Provider Demographics
NPI:1689290611
Name:MAXWELL, ROYAL BETTIS
Entity Type:Individual
Prefix:
First Name:ROYAL
Middle Name:BETTIS
Last Name:MAXWELL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 830208
Mailing Address - Street 2:
Mailing Address - City:TUSKEGEE
Mailing Address - State:AL
Mailing Address - Zip Code:36083-0208
Mailing Address - Country:US
Mailing Address - Phone:334-724-9856
Mailing Address - Fax:
Practice Address - Street 1:104 GAUTIER ST
Practice Address - Street 2:
Practice Address - City:TUSKEGEE
Practice Address - State:AL
Practice Address - Zip Code:36083-2645
Practice Address - Country:US
Practice Address - Phone:334-226-1454
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-25
Last Update Date:2020-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-169700163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse