Healthcare Provider Details

I. General information

NPI: 1386481265
Provider Name (Legal Business Name): MADISON NICHOLE YUNGERT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MADISON NICHOLE FOSS

II. Dates (important events)

Enumeration Date: 07/09/2024
Last Update Date: 06/30/2025
Certification Date: 06/30/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

711 STONY POINT RD STE 17
SANTA ROSA CA
95407-6848
US

IV. Provider business mailing address

351 WILSON ST
PETALUMA CA
94952-3141
US

V. Phone/Fax

Practice location:
  • Phone: 707-303-3600
  • Fax:
Mailing address:
  • Phone: 209-631-5208
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number95032719
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: