Provider Demographics
NPI:1972520781
Name:MAXWELL, KATHLEEN T (CNP)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:T
Last Name:MAXWELL
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24701 EUCLID AVE
Mailing Address - Street 2:3RD FLOOR
Mailing Address - City:EUCLID
Mailing Address - State:OH
Mailing Address - Zip Code:44117-1714
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11100 EUCLID AVE
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44106-1716
Practice Address - Country:US
Practice Address - Phone:216-844-7700
Practice Address - Fax:216-286-6341
Is Sole Proprietor?:No
Enumeration Date:2006-07-16
Last Update Date:2017-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCNP-019941363L00000X
OH3152-NS364SP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No364SP0200XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000224402OtherUNISON
OH000000372630OtherANTHEM
PA1018896160001Medicaid
OH2582192Medicaid
OH363818OtherWELLCARE
OH7768662OtherAETNA
OH000000526142OtherANTHEM
OH750908OtherBUCKEYE
PA1018896160001Medicaid
OHMANS03283Medicare PIN
OHQ51572Medicare UPIN
OHMANS03282Medicare PIN