Provider Demographics
NPI:1699190959
Name:MADRID, DAWNLYSETTE
Entity Type:Individual
Prefix:
First Name:DAWNLYSETTE
Middle Name:
Last Name:MADRID
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:DAWN
Other - Middle Name:
Other - Last Name:MADRID
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PPS
Mailing Address - Street 1:1800 TULLY RD STE A2
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95350-2923
Mailing Address - Country:US
Mailing Address - Phone:209-622-1420
Mailing Address - Fax:
Practice Address - Street 1:1800 TULLY RD STE A2
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95350-2923
Practice Address - Country:US
Practice Address - Phone:209-622-1420
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-02-24
Last Update Date:2014-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator