Basic Information
| Provider Information | |||||||||
| NPI: | 1740795038 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MAXIE | ||||||||
| FirstName: | SHAVONNE | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | RN | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 431 GRANT AVE | ||||||||
| Address2: | |||||||||
| City: | DOWNINGTOWN | ||||||||
| State: | PA | ||||||||
| PostalCode: | 193353013 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6104705711 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1400 BLACKHORSE HILL RD | ||||||||
| Address2: | |||||||||
| City: | COATESVILLE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 193202040 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6103847711 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/07/2017 | ||||||||
| LastUpdateDate: | 12/07/2017 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 700451 | PA | N | Nursing Service Providers | Registered Nurse | 163WH1000X | 700451 | PA | N | Nursing Service Providers | Registered Nurse | Hospice | 163WP0000X | 700451 | PA | N | Nursing Service Providers | Registered Nurse | Pain Management | 163WP0808X | 700451 | PA | Y | Nursing Service Providers | Registered Nurse | Psych/Mental Health |
No ID Information.