Provider Demographics
NPI:1235724139
Name:DEVAULT, MADISON MARIE (NP)
Entity Type:Individual
Prefix:
First Name:MADISON
Middle Name:MARIE
Last Name:DEVAULT
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:MADISON
Other - Middle Name:MARIE
Other - Last Name:WALTEMATH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:250 N SHADELAND AVE
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46219-4959
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:575 RILEY HOSPITAL DR # 4300
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202-5272
Practice Address - Country:US
Practice Address - Phone:317-944-8162
Practice Address - Fax:317-948-0609
Is Sole Proprietor?:No
Enumeration Date:2021-03-03
Last Update Date:2021-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28229350A163W00000X
IN71010915A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse