Provider Demographics
NPI:1588604300
Name:MADKIN, JUAQULA MICHELLE (RD, LD, MS)
Entity Type:Individual
Prefix:MRS
First Name:JUAQULA
Middle Name:MICHELLE
Last Name:MADKIN
Suffix:
Gender:F
Credentials:RD, LD, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:304 EARNHARDT DR
Mailing Address - Street 2:
Mailing Address - City:NEW MARKET
Mailing Address - State:AL
Mailing Address - Zip Code:35761-7917
Mailing Address - Country:US
Mailing Address - Phone:256-829-1470
Mailing Address - Fax:
Practice Address - Street 1:304 EARNHARDT DR
Practice Address - Street 2:
Practice Address - City:NEW MARKET
Practice Address - State:AL
Practice Address - Zip Code:35761-7917
Practice Address - Country:US
Practice Address - Phone:256-829-1470
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-08
Last Update Date:2012-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL924890133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered