Provider Demographics
NPI:1003690371
Name:FIETH, MADYSON BLAIRE
Entity Type:Individual
Prefix:
First Name:MADYSON
Middle Name:BLAIRE
Last Name:FIETH
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 1:2122 S PELZER RD
Mailing Address - Street 2:
Mailing Address - City:BOONVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47601-8225
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3700 WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:EVANSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47714-0541
Practice Address - Country:US
Practice Address - Phone:812-485-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-18
Last Update Date:2023-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28244315A163WM0705X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WM0705XNursing Service ProvidersRegistered NurseMedical-Surgical