Healthcare Provider Details

I. General information

NPI: 1265415103
Provider Name (Legal Business Name): MICHELLE JANE MADAN ARNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/23/2005
Last Update Date: 03/26/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 N WICKHAM RD SUITE S
MELBOURNE FL
32935-8659
US

IV. Provider business mailing address

269 PLANTATION DR
TITUSVILLE FL
32780-2555
US

V. Phone/Fax

Practice location:
  • Phone: 321-242-9031
  • Fax: 321-242-9035
Mailing address:
  • Phone: 321-383-9529
  • Fax: 321-383-9529

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberARNP9216767
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: