Provider Demographics
NPI:1710596234
Name:MADISON, NICHELLE RAIN
Entity Type:Individual
Prefix:
First Name:NICHELLE
Middle Name:RAIN
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 1:4901 N PEARL ST
Mailing Address - Street 2:
Mailing Address - City:RUSTON
Mailing Address - State:WA
Mailing Address - Zip Code:98407-3119
Mailing Address - Country:US
Mailing Address - Phone:253-370-8671
Mailing Address - Fax:
Practice Address - Street 1:4901 N PEARL ST
Practice Address - Street 2:
Practice Address - City:RUSTON
Practice Address - State:WA
Practice Address - Zip Code:98407-3119
Practice Address - Country:US
Practice Address - Phone:253-370-8671
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-30
Last Update Date:2020-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA61041341225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist