Provider Demographics
NPI:1457553760
Name:MADONNA'S WELL WOMAN INC
Entity Type:Organization
Organization Name:MADONNA'S WELL WOMAN INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MISS
Authorized Official - First Name:MADONNA
Authorized Official - Middle Name:MARY
Authorized Official - Last Name:HOLDER
Authorized Official - Suffix:
Authorized Official - Credentials:CNM
Authorized Official - Phone:718-977-0777
Mailing Address - Street 1:25412 MEMPHIS AVE
Mailing Address - Street 2:
Mailing Address - City:ROSEDALE
Mailing Address - State:NY
Mailing Address - Zip Code:11422-2545
Mailing Address - Country:US
Mailing Address - Phone:718-977-0777
Mailing Address - Fax:718-977-0778
Practice Address - Street 1:25412 MEMPHIS AVE
Practice Address - Street 2:
Practice Address - City:ROSEDALE
Practice Address - State:NY
Practice Address - Zip Code:11422-2545
Practice Address - Country:US
Practice Address - Phone:718-977-0777
Practice Address - Fax:718-977-0778
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-31
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYFOOOO88261QF0050X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0050XAmbulatory Health Care FacilitiesClinic/CenterFamily Planning, Non-Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01859723Medicaid