Healthcare Provider Details

I. General information

NPI: 1730715855
Provider Name (Legal Business Name): MADISON PAIGE KELLEY MAT, LAT, ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MADISON HIATT MAT, LAT, ATC

II. Dates (important events)

Enumeration Date: 03/20/2020
Last Update Date: 07/28/2026
Certification Date: 07/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

404 N MAIN ST
ENTERPRISE AL
36330-2563
US

IV. Provider business mailing address

404 N MAIN ST
ENTERPRISE AL
36330-2563
US

V. Phone/Fax

Practice location:
  • Phone: 334-393-7465
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberA161268622
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number3064
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: