Provider Demographics
NPI:1952174245
Name:TALLENT MAXWELL, KATIE (LMT)
Entity Type:Individual
Prefix:
First Name:KATIE
Middle Name:
Last Name:TALLENT MAXWELL
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:53140 N SHORE CT
Mailing Address - Street 2:
Mailing Address - City:KENAI
Mailing Address - State:AK
Mailing Address - Zip Code:99611-9642
Mailing Address - Country:US
Mailing Address - Phone:907-953-7874
Mailing Address - Fax:
Practice Address - Street 1:43335 KALIFORNSKY BEACH RD STE 16H
Practice Address - Street 2:
Practice Address - City:SOLDOTNA
Practice Address - State:AK
Practice Address - Zip Code:99669-8250
Practice Address - Country:US
Practice Address - Phone:907-953-7874
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-30
Last Update Date:2023-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK191587225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist