Provider Demographics
NPI:1114796133
Name:FERN, MADELYN JOANNE
Entity Type:Individual
Prefix:
First Name:MADELYN
Middle Name:JOANNE
Last Name:FERN
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 1:17105 NIXON CT NW
Mailing Address - Street 2:
Mailing Address - City:ELK RIVER
Mailing Address - State:MN
Mailing Address - Zip Code:55330-5000
Mailing Address - Country:US
Mailing Address - Phone:612-963-2646
Mailing Address - Fax:
Practice Address - Street 1:3401 ROUND LAKE BLVD NW
Practice Address - Street 2:
Practice Address - City:ANOKA
Practice Address - State:MN
Practice Address - Zip Code:55303-3315
Practice Address - Country:US
Practice Address - Phone:952-247-3582
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-02
Last Update Date:2024-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician