Healthcare Provider Details

I. General information

NPI: 1740928936
Provider Name (Legal Business Name): MADISON NICOLE WARREN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/26/2022
Last Update Date: 07/25/2022
Certification Date: 07/12/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1111 E MCDOWELL RD BLDG A
PHOENIX AZ
85006-2612
US

IV. Provider business mailing address

4360 E GRANADA RD
PHOENIX AZ
85008-4091
US

V. Phone/Fax

Practice location:
  • Phone: 602-521-5968
  • Fax: 602-521-5988
Mailing address:
  • Phone: 314-853-7298
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number275900
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number2016024603
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: