Healthcare Provider Details

I. General information

NPI: 1265967160
Provider Name (Legal Business Name): MAYLIN NICOLE MADRID
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/28/2017
Last Update Date: 04/28/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5787 VINELAND RD SUITE 104
ORLANDO FL
32819-7804
US

IV. Provider business mailing address

6917 SEA CORAL DR APT 104
ORLANDO FL
32821-8024
US

V. Phone/Fax

Practice location:
  • Phone: 407-354-3906
  • Fax:
Mailing address:
  • Phone: 786-316-6143
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberPTA 26497
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: