Healthcare Provider Details

I. General information

NPI: 1437090941
Provider Name (Legal Business Name): MADALYN JEANNE OLIVE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/01/2026
Last Update Date: 04/01/2026
Certification Date: 04/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

901 S NATIONAL AVE # PROF417
SPRINGFIELD MO
65897-0027
US

IV. Provider business mailing address

3051 S SOUTH VALLEY LN APT E1
SPRINGFIELD MO
65807-5752
US

V. Phone/Fax

Practice location:
  • Phone: 217-361-5805
  • Fax:
Mailing address:
  • Phone: 217-361-5805
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberO410-5500-5755
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberO410-5500-5755
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: