Healthcare Provider Details

I. General information

NPI: 1235284258
Provider Name (Legal Business Name): MISS ANNALISE MADSEN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/23/2007
Last Update Date: 09/18/2025
Certification Date: 09/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2235 MERCURY WAY STE 107
SANTA ROSA CA
95407-5472
US

IV. Provider business mailing address

2235 MERCURY WAY STE 107
SANTA ROSA CA
95407-5472
US

V. Phone/Fax

Practice location:
  • Phone: 707-571-5581
  • Fax: 707-571-5531
Mailing address:
  • Phone: 707-571-5575
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: