Provider Demographics
NPI:1710443031
Name:MADISON, MIKAELA CHEYENNE
Entity Type:Individual
Prefix:
First Name:MIKAELA
Middle Name:CHEYENNE
Last Name:MADISON
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:HC 31 BOX 53
Mailing Address - Street 2:
Mailing Address - City:JASPER
Mailing Address - State:AR
Mailing Address - Zip Code:72641-9408
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:HC 31 BOX 53
Practice Address - Street 2:
Practice Address - City:JASPER
Practice Address - State:AR
Practice Address - Zip Code:72641-9408
Practice Address - Country:US
Practice Address - Phone:870-715-5929
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-11
Last Update Date:2019-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator