Healthcare Provider Details

I. General information

NPI: 1265120968
Provider Name (Legal Business Name): MADELINE BROWN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/01/2023
Last Update Date: 09/08/2026
Certification Date: 09/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6641 KANIKSU ST
BONNERS FERRY ID
83805-7532
US

IV. Provider business mailing address

919 SILVER SPRINGS RD
MOYIE SPRINGS ID
83845-5036
US

V. Phone/Fax

Practice location:
  • Phone: 208-267-3655
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number3971848
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: