Provider Demographics
NPI:1558077495
Name:STAINES, MADISON
Entity Type:Individual
Prefix:
First Name:MADISON
Middle Name:
Last Name:STAINES
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 1:10727 DOMAIN DR APT 177
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78758-5044
Mailing Address - Country:US
Mailing Address - Phone:404-313-8389
Mailing Address - Fax:
Practice Address - Street 1:10727 DOMAIN DR APT 177
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78758-5044
Practice Address - Country:US
Practice Address - Phone:404-313-8389
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-24
Last Update Date:2023-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist
No171400000XOther Service ProvidersHealth & Wellness Coach