Provider Demographics
NPI:1982029864
Name:MADALON, NICOLE (ARNP-CNM)
Entity Type:Individual
Prefix:MS
First Name:NICOLE
Middle Name:
Last Name:MADALON
Suffix:
Gender:F
Credentials:ARNP-CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 BALTIMORE PL NW STE 105
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30308-2134
Mailing Address - Country:US
Mailing Address - Phone:404-474-2770
Mailing Address - Fax:
Practice Address - Street 1:1 BALTIMORE PL NW STE 105
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30308-2134
Practice Address - Country:US
Practice Address - Phone:773-206-8388
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-02-28
Last Update Date:2019-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2014002554367A00000X
IL209011060367A00000X
FLARNP9437823367A00000X
GARN274702367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL018447200Medicaid
FLIR190ZMedicare PIN