Provider Demographics
NPI:1790159044
Name:DAILLY, MADISEN
Entity Type:Individual
Prefix:MS
First Name:MADISEN
Middle Name:
Last Name:DAILLY
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 1:1267 PERU AVE E
Mailing Address - Street 2:
Mailing Address - City:PORT ORCHARD
Mailing Address - State:WA
Mailing Address - Zip Code:98366-8307
Mailing Address - Country:US
Mailing Address - Phone:360-621-8240
Mailing Address - Fax:
Practice Address - Street 1:2501 SE MILE HILL DR STE A101
Practice Address - Street 2:
Practice Address - City:PORT ORCHARD
Practice Address - State:WA
Practice Address - Zip Code:98366-3514
Practice Address - Country:US
Practice Address - Phone:360-895-4843
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-11-24
Last Update Date:2015-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60615521225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist