Provider Information for 1760776066
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ANDROMEDA MAXWELL
Sex: Female
NPI: 1760776066
Last Updated: 2022-07-11
Certification Date: 2022-07-11
Certification Date: 2022-07-11
Details
| Name | Value | ||||||||
|---|---|---|---|---|---|---|---|---|---|
| NPI | 1760776066 | ||||||||
| Enumeration Date | 2011-06-03 | ||||||||
| NPI Type | NPI-1 Individual | ||||||||
| Sole Proprietor | NO | ||||||||
| Status | Active | ||||||||
| Mailing Address | 920 UNIVERSITY DR RUSSELLVILLE, AR 72801-4303 United States Phone: 479-967-2322 | Fax: | ||||||||
| Primary Practice Address | 2301 S 56TH ST STE 104 FORT SMITH, AR 72903-3710 United States Phone: 479-967-2322 | Fax: | ||||||||
| Secondary Practice Address(es) | 7701 S ZERO ST | ||||||||
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