Provider Demographics
NPI:1912577552
Name:NICKENS, MADISON DALE
Entity Type:Individual
Prefix:
First Name:MADISON
Middle Name:DALE
Last Name:NICKENS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:41403 BERTVILLE RD
Mailing Address - Street 2:
Mailing Address - City:GONZALES
Mailing Address - State:LA
Mailing Address - Zip Code:70737-8939
Mailing Address - Country:US
Mailing Address - Phone:225-270-4418
Mailing Address - Fax:
Practice Address - Street 1:U S S WISCONSIN LOOP
Practice Address - Street 2:
Practice Address - City:PASCAGOULA
Practice Address - State:MS
Practice Address - Zip Code:39595-0001
Practice Address - Country:US
Practice Address - Phone:601-270-1430
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-27
Last Update Date:2021-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist