Provider Demographics
NPI:1891214631
Name:RIVENBARK, MADISON WHITLEY (CRNP)
Entity Type:Individual
Prefix:
First Name:MADISON
Middle Name:WHITLEY
Last Name:RIVENBARK
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1928
Mailing Address - Street 2:
Mailing Address - City:DOTHAN
Mailing Address - State:AL
Mailing Address - Zip Code:36302-1928
Mailing Address - Country:US
Mailing Address - Phone:334-790-9933
Mailing Address - Fax:
Practice Address - Street 1:1118 ROSS CLARK CIR
Practice Address - Street 2:
Practice Address - City:DOTHAN
Practice Address - State:AL
Practice Address - Zip Code:36301-3001
Practice Address - Country:US
Practice Address - Phone:334-712-3738
Practice Address - Fax:334-699-4897
Is Sole Proprietor?:No
Enumeration Date:2017-09-13
Last Update Date:2024-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-145217363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care