Provider Demographics
NPI:1649070855
Name:BRISTOL, MADELINE MIRANDA (NP)
Entity type:Individual
Prefix:
First Name:MADELINE
Middle Name:MIRANDA
Last Name:BRISTOL
Suffix:
Gender:
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:6739 FORT GREY CT
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89139-6461
Mailing Address - Country:US
Mailing Address - Phone:702-232-6073
Mailing Address - Fax:
Practice Address - Street 1:15811 AMBAUM BLVD SW
Practice Address - Street 2:
Practice Address - City:BURIEN
Practice Address - State:WA
Practice Address - Zip Code:98166-3066
Practice Address - Country:US
Practice Address - Phone:206-242-8211
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-03-17
Last Update Date:2025-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP61666273363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health