Healthcare Provider Details

I. General information

NPI: 1710869680
Provider Name (Legal Business Name): MADELINE GRACE STEWART NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/22/2025
Last Update Date: 07/22/2025
Certification Date: 07/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

909 W CANFIELD AVE
COEUR D ALENE ID
83815-9764
US

IV. Provider business mailing address

909 W CANFIELD AVE
COEUR D ALENE ID
83815-9764
US

V. Phone/Fax

Practice location:
  • Phone: 208-292-4006
  • Fax: 866-229-7081
Mailing address:
  • Phone: 208-292-4006
  • Fax: 866-229-7081

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081N0008X
TaxonomyNeuromuscular Medicine (Physical Medicine & Rehabilitation) Physician
License Number2771366
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code2081P0301X
TaxonomyBrain Injury Medicine (Physical Medicine & Rehabilitation) Physician
License Number2771366
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: