Provider Demographics
NPI:1114642865
Name:PELLICER, MADELYN (APRN)
Entity Type:Individual
Prefix:
First Name:MADELYN
Middle Name:
Last Name:PELLICER
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:MISS
Other - First Name:MADELYN
Other - Middle Name:ELYZABETH
Other - Last Name:AITKEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:APRN
Mailing Address - Street 1:201 HEALTH PARK BLVD STE 105
Mailing Address - Street 2:
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32086-5770
Mailing Address - Country:US
Mailing Address - Phone:904-824-1776
Mailing Address - Fax:904-825-1270
Practice Address - Street 1:201 HEALTH PARK BLVD STE 105
Practice Address - Street 2:
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32086-5770
Practice Address - Country:US
Practice Address - Phone:904-824-1776
Practice Address - Fax:904-825-1270
Is Sole Proprietor?:No
Enumeration Date:2022-10-05
Last Update Date:2022-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11021961363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health