Healthcare Provider Details

I. General information

NPI: 1437935152
Provider Name (Legal Business Name): GISSELLE MADRIGAL
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/07/2023
Last Update Date: 09/07/2023
Certification Date: 09/07/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 POPLAR AVE
MODESTO CA
95354-0510
US

IV. Provider business mailing address

100 POPLAR AVE
MODESTO CA
95354-0510
US

V. Phone/Fax

Practice location:
  • Phone: 209-523-4573
  • Fax:
Mailing address:
  • Phone: 209-523-4573
  • 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: