Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 156F00000X | Technician/Technologist |
NPI | 1275706939 |
---|---|
Provider Name | Mrs. Haneelia Jean Max |
First Address | Tuba City, AZ 86045-2489 |
Second Address | Tuba City, AZ 86045-2489 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 02/04/2008 |
Last Update Date | 02/04/2008 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
119596 | (05) | AZ |