Healthcare Provider Details

I. General information

NPI: 1083525778
Provider Name (Legal Business Name): MADELYN WHITLOCK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/14/2026
Last Update Date: 09/14/2026
Certification Date: 09/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

290 W 9 MILE RD
FERNDALE MI
48220-1794
US

IV. Provider business mailing address

4467 RONDELAY ST
COMMERCE TOWNSHIP MI
48382-4055
US

V. Phone/Fax

Practice location:
  • Phone: 248-398-7105
  • Fax:
Mailing address:
  • Phone: 947-465-0411
  • 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 StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: