1851462014 NPI number — MRS. JANET LEE MAXSON APNP, PHD

Table of content: DR. DANIELLE N PICKINPAUGH (NPI 1700453578)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1851462014 NPI number — MRS. JANET LEE MAXSON APNP, PHD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MAXSON
Provider First Name:
JANET
Provider Middle Name:
LEE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
APNP, PHD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1851462014
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/28/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
LEGACY HEALTH CLINIC
Provider Second Line Business Mailing Address:
1324 20TH AVE SW
Provider Business Mailing Address City Name:
MINOT
Provider Business Mailing Address State Name:
ND
Provider Business Mailing Address Postal Code:
58701-4040
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
701-838-6000
Provider Business Mailing Address Fax Number:
701-838-6024

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
315 MAIN ST S
Provider Second Line Business Practice Location Address:
SUITE 205
Provider Business Practice Location Address City Name:
MINOT
Provider Business Practice Location Address State Name:
ND
Provider Business Practice Location Address Postal Code:
58701-3956
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
701-857-5854
Provider Business Practice Location Address Fax Number:
701-857-5075
Provider Enumeration Date:
11/10/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363A00000X , with the licence number:  PAC0057 , registered in the state of ND ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LF0000X , with the licence number: R16251 , registered in the state of ND ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363L00000X , with the licence number: R-16251 , registered in the state of ND ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 23509 . This is a "ND BLUE SHIELD" identifier , issued by the state of ( ND ) . This identifiers is of the category "OTHER".