Provider Demographics
NPI:1215367669
Name:WARDELL, MADELEINE SOFO (APRN)
Entity Type:Individual
Prefix:
First Name:MADELEINE
Middle Name:SOFO
Last Name:WARDELL
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 776879
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-6879
Mailing Address - Country:US
Mailing Address - Phone:502-588-9490
Mailing Address - Fax:502-272-5116
Practice Address - Street 1:6411 VETERANS MEMORIAL PKWY STE 200
Practice Address - Street 2:
Practice Address - City:CRESTWOOD
Practice Address - State:KY
Practice Address - Zip Code:40014-8698
Practice Address - Country:US
Practice Address - Phone:502-394-6555
Practice Address - Fax:502-394-3657
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-22
Last Update Date:2024-04-11
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
KY3009056363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY3009056OtherLICENSE