Provider Demographics
NPI:1801664222
Name:STUCKEY, MADISON BENNETT
Entity type:Individual
Prefix:
First Name:MADISON
Middle Name:BENNETT
Last Name:STUCKEY
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 1:468 ROBIN RD
Mailing Address - Street 2:
Mailing Address - City:GRENADA
Mailing Address - State:MS
Mailing Address - Zip Code:38901-1723
Mailing Address - Country:US
Mailing Address - Phone:662-699-0040
Mailing Address - Fax:
Practice Address - Street 1:1240 FAIRGROUND RD
Practice Address - Street 2:
Practice Address - City:GRENADA
Practice Address - State:MS
Practice Address - Zip Code:38901-4516
Practice Address - Country:US
Practice Address - Phone:662-226-3711
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-14
Last Update Date:2023-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS906398363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner