Provider Demographics
NPI:1902266307
Name:MAXSON, BRENDA (LPN)
Entity Type:Individual
Prefix:
First Name:BRENDA
Middle Name:
Last Name:MAXSON
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9 BALMAT FOWLER RD
Mailing Address - Street 2:
Mailing Address - City:GOUVERNEUR
Mailing Address - State:NY
Mailing Address - Zip Code:13642-3351
Mailing Address - Country:US
Mailing Address - Phone:315-287-7697
Mailing Address - Fax:
Practice Address - Street 1:56 MARKET ST
Practice Address - Street 2:
Practice Address - City:POTSDAM
Practice Address - State:NY
Practice Address - Zip Code:13676-1747
Practice Address - Country:US
Practice Address - Phone:315-256-4065
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-02-26
Last Update Date:2016-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY232836-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse