Healthcare Provider Details

I. General information

NPI: 1164140059
Provider Name (Legal Business Name): MADELYNNE GRACE RUNYON MSAT, LAT, ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/17/2022
Last Update Date: 12/10/2025
Certification Date: 12/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 W WABASH AVE
CRAWFORDSVILLE IN
47933-2428
US

IV. Provider business mailing address

844 SETTLERS WALK
BROWNSBURG IN
46112-7564
US

V. Phone/Fax

Practice location:
  • Phone: 765-361-6366
  • Fax:
Mailing address:
  • Phone: 317-409-9156
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number36003897A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: