Provider Demographics
NPI:1689355794
Name:TICKNOR, MADALYN
Entity Type:Individual
Prefix:
First Name:MADALYN
Middle Name:
Last Name:TICKNOR
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:PO BOX 84813
Mailing Address - Street 2:
Mailing Address - City:FAIRBANKS
Mailing Address - State:AK
Mailing Address - Zip Code:99708-4813
Mailing Address - Country:US
Mailing Address - Phone:907-371-4977
Mailing Address - Fax:
Practice Address - Street 1:1734 FALL RD
Practice Address - Street 2:
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99709-6727
Practice Address - Country:US
Practice Address - Phone:907-371-4977
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-31
Last Update Date:2023-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker