Healthcare Provider Details

I. General information

NPI: 1710745054
Provider Name (Legal Business Name): MADELINE TISDALE WADDELL
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/11/2024
Last Update Date: 05/02/2024
Certification Date: 05/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3104 BLUE LAKE DR STE 110
VESTAVIA AL
35243-2372
US

IV. Provider business mailing address

1512 LINDA VISTA DR
VESTAVIA AL
35226-3520
US

V. Phone/Fax

Practice location:
  • Phone: 205-977-1949
  • Fax:
Mailing address:
  • Phone: 865-804-6526
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number1-169544
License Number StateAL
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number148527
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: