Provider Demographics
NPI:1780887109
Name:MAXWELL, THERESA RENE (RN, MSN, FNP)
Entity type:Individual
Prefix:
First Name:THERESA
Middle Name:RENE
Last Name:MAXWELL
Suffix:
Gender:F
Credentials:RN, MSN, FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Mailing Address - Street 1:509 N LEONARD RD
Mailing Address - Street 2:
Mailing Address - City:SAINT JOSEPH
Mailing Address - State:MO
Mailing Address - Zip Code:64506-4024
Mailing Address - Country:US
Mailing Address - Phone:816-232-0185
Mailing Address - Fax:816-364-6225
Practice Address - Street 1:1011 E SAINT MAARTENS DR
Practice Address - Street 2:
Practice Address - City:SAINT JOSEPH
Practice Address - State:MO
Practice Address - Zip Code:64506-2993
Practice Address - Country:US
Practice Address - Phone:816-232-0185
Practice Address - Fax:816-364-6225
Is Sole Proprietor?:No
Enumeration Date:2007-06-06
Last Update Date:2013-09-25
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MO096655363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO624003109Medicaid
MO1255950001Medicare NSC