Healthcare Provider Details

I. General information

NPI: 1538030440
Provider Name (Legal Business Name): MADISON GRACE TARGGART
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/15/2025
Last Update Date: 09/15/2025
Certification Date: 09/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2024 GRANNY SMITH PL
KENDALLVILLE IN
46755-2874
US

IV. Provider business mailing address

2024 GRANNY SMITH PL
KENDALLVILLE IN
46755-2874
US

V. Phone/Fax

Practice location:
  • Phone: 260-582-9099
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: