Healthcare Provider Details

I. General information

NPI: 1285282988
Provider Name (Legal Business Name): MADELYN WILCOX RD, CSO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MADELYN DRUMM RD, CSO

II. Dates (important events)

Enumeration Date: 08/27/2019
Last Update Date: 04/15/2025
Certification Date: 04/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3850 S NATIONAL AVE STE 600
SPRINGFIELD MO
65807-5230
US

IV. Provider business mailing address

PO BOX 749495
ATLANTA GA
30374-9495
US

V. Phone/Fax

Practice location:
  • Phone: 417-882-4880
  • Fax: 417-882-7843
Mailing address:
  • Phone: 855-963-2100
  • Fax: 813-321-1296

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number86001617
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: