Healthcare Provider Details

I. General information

NPI: 1952150211
Provider Name (Legal Business Name): MADISON MULLIS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/17/2024
Last Update Date: 09/04/2024
Certification Date: 09/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1950 ARLINGTON ST STE 203
SARASOTA FL
34239-3516
US

IV. Provider business mailing address

2175 W DOLPHIN DR
ENGLEWOOD FL
34223-6310
US

V. Phone/Fax

Practice location:
  • Phone: 941-379-6331
  • Fax: 941-379-5443
Mailing address:
  • Phone: 941-716-4788
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9119173
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: