Provider Demographics
NPI:1679256457
Name:MAXWELL, FATIMA MEG
Entity type:Individual
Prefix:
First Name:FATIMA
Middle Name:MEG
Last Name: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 1:12613 TAYLORSVILLE RD STE 118
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40299-5496
Mailing Address - Country:US
Mailing Address - Phone:502-267-1480
Mailing Address - Fax:
Practice Address - Street 1:12613 TAYLORSVILLE RD STE 118
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40299-5496
Practice Address - Country:US
Practice Address - Phone:502-267-1480
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-09
Last Update Date:2023-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY008890225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist