Provider Demographics
NPI:1871157164
Name:MAXWELL, DEEARNEST ANTHONY
Entity type:Individual
Prefix:
First Name:DEEARNEST
Middle Name:ANTHONY
Last Name:MAXWELL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7411 S LAND PARK DR APT 13
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95831-5102
Mailing Address - Country:US
Mailing Address - Phone:916-578-4083
Mailing Address - Fax:
Practice Address - Street 1:8325 SOUTHFIELDS CIR
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95828-4924
Practice Address - Country:US
Practice Address - Phone:916-578-4083
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-23
Last Update Date:2019-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program