Provider Demographics
NPI:1417627092
Name:COLLIVER, MADISON
Entity Type:Individual
Prefix:
First Name:MADISON
Middle Name:
Last Name:COLLIVER
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 1:109 S GLENN ST
Mailing Address - Street 2:
Mailing Address - City:HILLSBORO
Mailing Address - State:OH
Mailing Address - Zip Code:45133-1210
Mailing Address - Country:US
Mailing Address - Phone:937-205-7929
Mailing Address - Fax:
Practice Address - Street 1:421 N HIGH ST
Practice Address - Street 2:
Practice Address - City:HILLSBORO
Practice Address - State:OH
Practice Address - Zip Code:45133-1132
Practice Address - Country:US
Practice Address - Phone:937-393-1734
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-15
Last Update Date:2021-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRN.466196163WG0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WG0000XNursing Service ProvidersRegistered NurseGeneral Practice