Basic Information
| Provider Information | |||||||||
| NPI: | 1962742460 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MAXWELL | ||||||||
| FirstName: | CHARLENE | ||||||||
| MiddleName: | AFABLE | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 421 SW OAK ST | ||||||||
| Address2: | STE. 210 | ||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972041817 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5039887468 | ||||||||
| FaxNumber: | 5039883015 | ||||||||
| Practice Location | |||||||||
| Address1: | 600 NE 8TH ST | ||||||||
| Address2: | #300 | ||||||||
| City: | GRESHAM | ||||||||
| State: | OR | ||||||||
| PostalCode: | 970307317 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5039885155 | ||||||||
| FaxNumber: | 5099885185 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/20/2013 | ||||||||
| LastUpdateDate: | 08/11/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 201391238NP-PP | OR | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 096511 | 05 | OR | MEDICAID | 22959 | 05 | OR | MEDICAID |