Provider Demographics
NPI:1821384371
Name:MAXWELL, KEVIN JOHN (FNP)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:JOHN
Last Name:MAXWELL
Suffix:
Gender:M
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1504 CYPRESS AVE
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92103-4517
Mailing Address - Country:US
Mailing Address - Phone:619-750-5502
Mailing Address - Fax:
Practice Address - Street 1:6973 LINDA VISTA RD
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92111-6342
Practice Address - Country:US
Practice Address - Phone:858-279-0925
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-23
Last Update Date:2011-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20902363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily