Provider Demographics
NPI:1376015438
Name:FIMPLE, MADELYNNE (LMT/MMP, OTA)
Entity Type:Individual
Prefix:
First Name:MADELYNNE
Middle Name:
Last Name:FIMPLE
Suffix:
Gender:F
Credentials:LMT/MMP, OTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8057 WHITEHART ST
Mailing Address - Street 2:
Mailing Address - City:FRISCO
Mailing Address - State:TX
Mailing Address - Zip Code:75035-3166
Mailing Address - Country:US
Mailing Address - Phone:469-406-9123
Mailing Address - Fax:
Practice Address - Street 1:8057 WHITEHART ST
Practice Address - Street 2:
Practice Address - City:FRISCO
Practice Address - State:TX
Practice Address - Zip Code:75035-3166
Practice Address - Country:US
Practice Address - Phone:469-406-9123
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-28
Last Update Date:2018-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXMT107685173C00000X, 174400000X, 225400000X, 251E00000X, 225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
No173C00000XOther Service ProvidersReflexologist
No174400000XOther Service ProvidersSpecialist
No225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner
No251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXMT107685OtherMASSAGE THERAPY LICENSE