Provider Demographics
NPI:1821829433
Name:MADISON, ANNELISE ALISSA (PHD)
Entity type:Individual
Prefix:
First Name:ANNELISE
Middle Name:ALISSA
Last Name:MADISON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:471 DUPONT AVE
Mailing Address - Street 2:
Mailing Address - City:YPSILANTI
Mailing Address - State:MI
Mailing Address - Zip Code:48197-1911
Mailing Address - Country:US
Mailing Address - Phone:402-499-3213
Mailing Address - Fax:
Practice Address - Street 1:210 S 5TH AVE
Practice Address - Street 2:
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48104-2216
Practice Address - Country:US
Practice Address - Phone:734-764-3471
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-13
Last Update Date:2024-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program