Healthcare Provider Details

I. General information

NPI: 1902700347
Provider Name (Legal Business Name): MADELYNN MARTIN LAC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/07/2026
Last Update Date: 10/07/2026
Certification Date: 10/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7287 E EARLL DR
SCOTTSDALE AZ
85251-7230
US

IV. Provider business mailing address

5225 E THOMAS RD APT 137
PHOENIX AZ
85018-8005
US

V. Phone/Fax

Practice location:
  • Phone: 480-418-1570
  • Fax: 480-956-0806
Mailing address:
  • Phone: 602-469-9169
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberLAC-24254
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: