Provider Demographics
NPI:1013431253
Name:MADDOX, NICOLE RENEE (DC)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:RENEE
Last Name:MADDOX
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1839 S ALMA SCHOOL RD STE 354
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85210-3028
Mailing Address - Country:US
Mailing Address - Phone:480-726-2287
Mailing Address - Fax:888-316-9272
Practice Address - Street 1:15256 N 75TH AVE STE 360
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:AZ
Practice Address - Zip Code:85381-4761
Practice Address - Country:US
Practice Address - Phone:623-486-2424
Practice Address - Fax:623-486-4324
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-31
Last Update Date:2020-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO7855111N00000X
MO2017015756111N00000X
AZ8942111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO2017015756OtherMISSOURI STATE BOARD OF CHIROPRACTIC EXAMINERS