Provider Demographics
NPI:1396315974
Name:RICKETTS, MADELINE (CRNA)
Entity type:Individual
Prefix:
First Name:MADELINE
Middle Name:
Last Name:RICKETTS
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4633 RIVERVIEW DR
Mailing Address - Street 2:
Mailing Address - City:HOOVER
Mailing Address - State:AL
Mailing Address - Zip Code:35244-3718
Mailing Address - Country:US
Mailing Address - Phone:205-451-2499
Mailing Address - Fax:
Practice Address - Street 1:1615 CAHABA RIVER PARC
Practice Address - Street 2:
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35243-3271
Practice Address - Country:US
Practice Address - Phone:205-451-2499
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-28
Last Update Date:2023-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-150686367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered