Healthcare Provider Details

I. General information

NPI: 1235225491
Provider Name (Legal Business Name): MADELEINE CISSNA AUD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/05/2006
Last Update Date: 08/02/2021
Certification Date: 08/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11014 GLUECK LN
KENSINGTON MD
20895-1618
US

IV. Provider business mailing address

11014 GLUECK LN
KENSINGTON MD
20895-1618
US

V. Phone/Fax

Practice location:
  • Phone: 301-221-2208
  • Fax:
Mailing address:
  • Phone: 301-221-2208
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code231H00000X
TaxonomyAudiologist
License NumberAT005812
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code231H00000X
TaxonomyAudiologist
License Number00931
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: