Provider Demographics
NPI:1710331152
Name:MADLOCK, DANIELLE (APRN)
Entity Type:Individual
Prefix:
First Name:DANIELLE
Middle Name:
Last Name:MADLOCK
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4696 BALLEY SHANNON DR SE
Mailing Address - Street 2:
Mailing Address - City:MABLETON
Mailing Address - State:GA
Mailing Address - Zip Code:30126-1763
Mailing Address - Country:US
Mailing Address - Phone:678-360-2368
Mailing Address - Fax:
Practice Address - Street 1:5701 MABLETON PKWY SW STE 348
Practice Address - Street 2:
Practice Address - City:MABLETON
Practice Address - State:GA
Practice Address - Zip Code:30126-3395
Practice Address - Country:US
Practice Address - Phone:470-454-3653
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-22
Last Update Date:2020-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN208494163W00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse