Provider Demographics
NPI:1073091013
Name:MADISON, PRISCILLA JOANN (NP)
Entity Type:Individual
Prefix:
First Name:PRISCILLA
Middle Name:JOANN
Last Name:MADISON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:PRISCILLA
Other - Middle Name:JOANN
Other - Last Name:BEDOLLA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:961 E CALIFORNIA BLVD UNIT 104
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91106-4057
Mailing Address - Country:US
Mailing Address - Phone:323-348-8015
Mailing Address - Fax:
Practice Address - Street 1:1680 E 120TH ST
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90059-3026
Practice Address - Country:US
Practice Address - Phone:424-338-8000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-01
Last Update Date:2019-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95009290363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner