Healthcare Provider Details

I. General information

NPI: 1881259513
Provider Name (Legal Business Name): MADELINE EMLAW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/08/2019
Last Update Date: 05/08/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21395 JOHN MILLESS DR STE 100
ROGERS MN
55374-4404
US

IV. Provider business mailing address

21395 JOHN MILLESS DR STE 100
ROGERS MN
55374-4404
US

V. Phone/Fax

Practice location:
  • Phone: 763-504-6400
  • Fax:
Mailing address:
  • Phone: 763-504-6400
  • 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 State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: