Healthcare Provider Details

I. General information

NPI: 1417778291
Provider Name (Legal Business Name): MADISON TAYLOR WILSON NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/23/2024
Last Update Date: 11/22/2024
Certification Date: 11/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

850 W IRONWOOD DR STE 202
COEUR D ALENE ID
83814-4903
US

IV. Provider business mailing address

850 W IRONWOOD DR
COEUR D ALENE ID
83814-4903
US

V. Phone/Fax

Practice location:
  • Phone: 208-664-2175
  • Fax: 208-664-1226
Mailing address:
  • Phone: 208-664-2175
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number8971836
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number68709
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: