Provider Demographics
NPI:1578259602
Name:MADON MAKEM, BRUNETTE LARISSA
Entity Type:Individual
Prefix:
First Name:BRUNETTE LARISSA
Middle Name:
Last Name:MADON MAKEM
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 1:148 N MAIN ST APT B
Mailing Address - Street 2:
Mailing Address - City:TIMBERVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:22853-9538
Mailing Address - Country:US
Mailing Address - Phone:540-209-2868
Mailing Address - Fax:
Practice Address - Street 1:148 N MAIN ST APT B
Practice Address - Street 2:
Practice Address - City:TIMBERVILLE
Practice Address - State:VA
Practice Address - Zip Code:22853-9538
Practice Address - Country:US
Practice Address - Phone:540-209-2868
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-12
Last Update Date:2023-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide