Provider Demographics
NPI:1508904673
Name:MADDOX, MICHELLE ELLAINE (CMA)
Entity Type:Individual
Prefix:MRS
First Name:MICHELLE
Middle Name:ELLAINE
Last Name:MADDOX
Suffix:
Gender:F
Credentials:CMA
Other - Prefix:MISS
Other - First Name:MICHELLE
Other - Middle Name:ELAINE
Other - Last Name:JORDAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4477 MEDICAL CENTER WAY
Mailing Address - Street 2:SUITE A
Mailing Address - City:WEST PALM BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33407-3257
Mailing Address - Country:US
Mailing Address - Phone:561-840-7977
Mailing Address - Fax:
Practice Address - Street 1:4477 MEDICAL CENTER WAY
Practice Address - Street 2:SUITE A
Practice Address - City:WEST PALM BEACH
Practice Address - State:FL
Practice Address - Zip Code:33407-3257
Practice Address - Country:US
Practice Address - Phone:561-840-7977
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL55528174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist