Provider Demographics
NPI:1265238075
Name:TAVIS, MADISON JAZLYNN (CNA)
Entity type:Individual
Prefix:
First Name:MADISON
Middle Name:JAZLYNN
Last Name:TAVIS
Suffix:
Gender:
Credentials:CNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:62296 736 RD # NE68329
Mailing Address - Street 2:
Mailing Address - City:COOK
Mailing Address - State:NE
Mailing Address - Zip Code:68329-9612
Mailing Address - Country:US
Mailing Address - Phone:402-269-6754
Mailing Address - Fax:
Practice Address - Street 1:62296 736 RD # NE68329
Practice Address - Street 2:
Practice Address - City:COOK
Practice Address - State:NE
Practice Address - Zip Code:68329-9612
Practice Address - Country:US
Practice Address - Phone:402-269-6754
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-02-21
Last Update Date:2025-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE140744376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes376K00000XNursing Service Related ProvidersNurse's AideGroup - Multi-Specialty