Individual
MAXEEN WYATT
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
MT
Contact information
Practice address
380 WESTERN AVE, SOUTH PORTLAND, ME 04106-1720
(207) 282-5110
Mailing address
380 WESTERN AVE, SOUTH PORTLAND, ME 04106-1720
(207) 239-4240
Taxonomy
Speciality
Code
Description
License number
State
174400000X
Specialist
Primary
MT3231
ME
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
200890
ANTHEM BLUE CROSS BLUE SHIELD
ME
Enumeration date
06/06/2008
Last updated
06/06/2008
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