Healthcare Provider Details

I. General information

NPI: 1104476563
Provider Name (Legal Business Name): MADELEINE SEDLACK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/18/2019
Last Update Date: 08/07/2024
Certification Date: 08/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

248 W 108TH ST
NEW YORK NY
10025-2956
US

IV. Provider business mailing address

248 W 108TH ST
NEW YORK NY
10025-2956
US

V. Phone/Fax

Practice location:
  • Phone: 212-663-3000
  • Fax:
Mailing address:
  • Phone: 212-663-3000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN2328803
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number851516
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberRN2328803
License Number StateMA
# 4
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberRN2328803
License Number StateMA
# 5
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number404502
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: