Provider Demographics
NPI:1780291419
Name:STEWART, MADISON TAYLOR (LAT, ATC)
Entity type:Individual
Prefix:
First Name:MADISON
Middle Name:TAYLOR
Last Name:STEWART
Suffix:
Gender:F
Credentials:LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3205 NW 83RD ST APT 1124
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32606-6229
Mailing Address - Country:US
Mailing Address - Phone:765-426-2664
Mailing Address - Fax:
Practice Address - Street 1:4100 NW 115TH TER
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32606-3604
Practice Address - Country:US
Practice Address - Phone:352-376-6545
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-27
Last Update Date:2023-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
FL2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program