Healthcare Provider Details

I. General information

NPI: 1104734177
Provider Name (Legal Business Name): MADISON ANN PLOURDE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/31/2026
Last Update Date: 08/31/2026
Certification Date: 08/31/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

177 FORT WASHINGTON AVE
NEW YORK NY
10032-3733
US

IV. Provider business mailing address

17 WIIGS RD
NESCONSET NY
11767-2616
US

V. Phone/Fax

Practice location:
  • Phone: 631-830-7292
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835P1300X
TaxonomyPsychiatric Pharmacist
License Number071796
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: