Provider Demographics
NPI:1831833474
Name:PARK-MAXWELL, PAULINE ANDREA (APN)
Entity type:Individual
Prefix:
First Name:PAULINE
Middle Name:ANDREA
Last Name:PARK-MAXWELL
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:339 HILLCREST AVE
Mailing Address - Street 2:
Mailing Address - City:EWING
Mailing Address - State:NJ
Mailing Address - Zip Code:08618-2509
Mailing Address - Country:US
Mailing Address - Phone:609-233-1211
Mailing Address - Fax:
Practice Address - Street 1:1542 KUSER RD STE B7
Practice Address - Street 2:
Practice Address - City:HAMILTON
Practice Address - State:NJ
Practice Address - Zip Code:08619-3829
Practice Address - Country:US
Practice Address - Phone:609-989-9211
Practice Address - Fax:609-896-0249
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-20
Last Update Date:2023-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NJ01168800363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0892823Medicaid