Provider Demographics
NPI:1720569858
Name:MAXWELL, MARCIA ANN
Entity Type:Individual
Prefix:
First Name:MARCIA
Middle Name:ANN
Last Name:MAXWELL
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 1:5057 N 19TH ST
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53209-5762
Mailing Address - Country:US
Mailing Address - Phone:414-716-5971
Mailing Address - Fax:414-716-5109
Practice Address - Street 1:5057 N 19TH ST
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53209-5762
Practice Address - Country:US
Practice Address - Phone:414-716-5971
Practice Address - Fax:414-716-5109
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-27
Last Update Date:2021-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI323472-31164W00000X
251J00000X, 310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
No164W00000XNursing Service ProvidersLicensed Practical Nurse
No251J00000XAgenciesNursing Care