Healthcare Provider Details

I. General information

NPI: 1396312823
Provider Name (Legal Business Name): MS. MADISON EDWARDS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/03/2021
Last Update Date: 05/23/2023
Certification Date: 05/23/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1722 S LEWIS RD
CAMARILLO CA
93012-8520
US

IV. Provider business mailing address

3858 LOST SPRINGS DR
AGOURA HILLS CA
91301-5322
US

V. Phone/Fax

Practice location:
  • Phone: 805-366-4040
  • Fax:
Mailing address:
  • Phone: 661-204-3424
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: