Provider Demographics
NPI:1740798925
Name:MADISON, LUE R
Entity type:Individual
Prefix:
First Name:LUE
Middle Name:R
Last Name:MADISON
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 1:15207 SW 114TH PL
Mailing Address - Street 2:
Mailing Address - City:ARCHER
Mailing Address - State:FL
Mailing Address - Zip Code:32618-3923
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:15207 SW 114TH PL
Practice Address - Street 2:
Practice Address - City:ARCHER
Practice Address - State:FL
Practice Address - Zip Code:32618-3923
Practice Address - Country:US
Practice Address - Phone:352-275-3070
Practice Address - Fax:352-495-3131
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-22
Last Update Date:2018-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL141949376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes376K00000XNursing Service Related ProvidersNurse's AideGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLD9916297OtherSECURITY OFFICER