Provider Demographics
NPI:1053900738
Name:WEDDERBURN-MAXWELL, SARA LYNN
Entity type:Individual
Prefix:
First Name:SARA
Middle Name:LYNN
Last Name:WEDDERBURN-MAXWELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4914 OCTOBER WAY NW
Mailing Address - Street 2:
Mailing Address - City:ACWORTH
Mailing Address - State:GA
Mailing Address - Zip Code:30102-7909
Mailing Address - Country:US
Mailing Address - Phone:908-884-5442
Mailing Address - Fax:
Practice Address - Street 1:4914 OCTOBER WAY NW
Practice Address - Street 2:
Practice Address - City:ACWORTH
Practice Address - State:GA
Practice Address - Zip Code:30102-7909
Practice Address - Country:US
Practice Address - Phone:908-884-5442
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-15
Last Update Date:2021-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA3747A0650X3747A0650X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider