Provider Demographics
NPI:1205481298
Name:WISLEY, MADISON (ATC)
Entity type:Individual
Prefix:
First Name:MADISON
Middle Name:
Last Name:WISLEY
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 CORPORATE DR STE 400
Mailing Address - Street 2:
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35242-5424
Mailing Address - Country:US
Mailing Address - Phone:423-238-8930
Mailing Address - Fax:
Practice Address - Street 1:4626 HIGHWAY 58
Practice Address - Street 2:
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37416-3013
Practice Address - Country:US
Practice Address - Phone:423-553-7972
Practice Address - Fax:423-553-7973
Is Sole Proprietor?:No
Enumeration Date:2019-08-06
Last Update Date:2019-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN24802255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer