Basic Information
| Provider Information | |||||||||
| NPI: | 1609897388 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MAXWELL | ||||||||
| FirstName: | KATHIE | ||||||||
| MiddleName: | SUE | ||||||||
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| Credential: | CNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 201 CEDAR ST SE STE 405 | ||||||||
| Address2: | |||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871064924 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5057649535 | ||||||||
| FaxNumber: | 5059247336 | ||||||||
| Practice Location | |||||||||
| Address1: | 201 CEDAR ST SE STE 405 | ||||||||
| Address2: | |||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871064924 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5057649535 | ||||||||
| FaxNumber: | 5059247336 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/21/2006 | ||||||||
| LastUpdateDate: | 08/25/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367A00000X | 547 | NM | Y | Physician Assistants & Advanced Practice Nursing Providers | Advanced Practice Midwife |
ID Information
| ID | Type | State | Issuer | Description | 56639848 | 05 | NM | MEDICAID | 797376 | 01 | AZ | MEDICAID | OTHER |