Provider Demographics
NPI:1275902991
Name:MADRIGAL, PATTY KAY
Entity Type:Individual
Prefix:
First Name:PATTY
Middle Name:KAY
Last Name:MADRIGAL
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 1:204 S WASHINGTON AVE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:ALBERT LEA
Mailing Address - State:MN
Mailing Address - Zip Code:56007-2555
Mailing Address - Country:US
Mailing Address - Phone:507-369-5701
Mailing Address - Fax:507-369-5702
Practice Address - Street 1:204 S WASHINGTON AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:ALBERT LEA
Practice Address - State:MN
Practice Address - Zip Code:56007-2555
Practice Address - Country:US
Practice Address - Phone:507-369-5701
Practice Address - Fax:507-369-5702
Is Sole Proprietor?:No
Enumeration Date:2015-09-23
Last Update Date:2015-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR 170893-1163W00000X
MNR-191526-2163W00000X
MN222421-1163W00000X
MNL 073655-2164W00000X
MN79540-9164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNA522457100Medicaid
MNA697988100Medicaid
MN1477843209Medicaid