Provider Demographics
NPI:1174178370
Name:WICKLINE, MADISON MARIE
Entity Type:Individual
Prefix:
First Name:MADISON
Middle Name:MARIE
Last Name:WICKLINE
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 1:980 JOHNSON FERRY RD STE 1040
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30342-1609
Mailing Address - Country:US
Mailing Address - Phone:770-292-3490
Mailing Address - Fax:404-300-2317
Practice Address - Street 1:980 JOHNSON FERRY RD STE 1040
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30342-1609
Practice Address - Country:US
Practice Address - Phone:770-292-3490
Practice Address - Fax:404-300-2317
Is Sole Proprietor?:No
Enumeration Date:2019-08-05
Last Update Date:2021-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
GA10258363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program