Provider Demographics
NPI:1083399893
Name:WEATHERS, MADELYNN RAE
Entity type:Individual
Prefix:
First Name:MADELYNN
Middle Name:RAE
Last Name:WEATHERS
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 1:700 N 4TH ST APT 908
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85004-0733
Mailing Address - Country:US
Mailing Address - Phone:360-325-2645
Mailing Address - Fax:
Practice Address - Street 1:5130 N US HIGHWAY 89
Practice Address - Street 2:
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86004-2837
Practice Address - Country:US
Practice Address - Phone:928-773-2054
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-19
Last Update Date:2025-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZOTH-010103225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist