Healthcare Provider Details

I. General information

NPI: 1992339626
Provider Name (Legal Business Name): JESSICA MADOW APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/03/2020
Last Update Date: 07/22/2026
Certification Date: 07/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 W 45TH ST FL 21
NEW YORK NY
10036-4041
US

IV. Provider business mailing address

3009 STANFIELD AVE
ORLANDO FL
32814-6778
US

V. Phone/Fax

Practice location:
  • Phone: 313-887-0960
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberAPRN11006403
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: