Provider Demographics
NPI:1699351346
Name:MADISON, TYCHNIA RENEE (OD)
Entity Type:Individual
Prefix:
First Name:TYCHNIA
Middle Name:RENEE
Last Name:MADISON
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1950 OLD GALLOWS RD STE 520
Mailing Address - Street 2:
Mailing Address - City:VIENNA
Mailing Address - State:VA
Mailing Address - Zip Code:22182-3970
Mailing Address - Country:US
Mailing Address - Phone:703-847-8899
Mailing Address - Fax:571-223-6780
Practice Address - Street 1:11761 US 70 BUSINESS HWY W STE 25
Practice Address - Street 2:
Practice Address - City:CLAYTON
Practice Address - State:NC
Practice Address - Zip Code:27520-2274
Practice Address - Country:US
Practice Address - Phone:919-553-5600
Practice Address - Fax:919-553-6707
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-23
Last Update Date:2022-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2645152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist