Healthcare Provider Details

I. General information

NPI: 1578486890
Provider Name (Legal Business Name): MADISON TANKERSLEY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/03/2026
Last Update Date: 08/03/2026
Certification Date: 08/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1062 THOMPSON BRIDGE RD STE B2
GAINESVILLE GA
30501-1757
US

IV. Provider business mailing address

5807 JIM CROW RD
FLOWERY BRANCH GA
30542-2502
US

V. Phone/Fax

Practice location:
  • Phone: 470-252-6846
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT017334
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: