Provider Demographics
NPI:1336909290
Name:WALL, MADISON NICOLE
Entity Type:Individual
Prefix:
First Name:MADISON
Middle Name:NICOLE
Last Name:WALL
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 1:2597 4TH AVE
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON
Mailing Address - State:WV
Mailing Address - Zip Code:25703-1603
Mailing Address - Country:US
Mailing Address - Phone:304-610-2717
Mailing Address - Fax:
Practice Address - Street 1:975 E 3RD ST
Practice Address - Street 2:
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37403-2173
Practice Address - Country:US
Practice Address - Phone:423-778-7000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-19
Last Update Date:2024-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program