Healthcare Provider Details

I. General information

NPI: 1619760782
Provider Name (Legal Business Name): MADELINE GRACE REAGAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MADELINE CLEMENTS PA

II. Dates (important events)

Enumeration Date: 05/22/2025
Last Update Date: 06/17/2026
Certification Date: 06/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4035 MIMOSA DR
COLUMBUS IN
47201-7200
US

IV. Provider business mailing address

PO BOX 781076
DETROIT MI
48278-1076
US

V. Phone/Fax

Practice location:
  • Phone: 831-786-5904
  • Fax: 317-867-5321
Mailing address:
  • Phone: 317-528-4800
  • Fax: 317-865-1479

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number10004926A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: