Healthcare Provider Details

I. General information

NPI: 1104660919
Provider Name (Legal Business Name): MADISON WELLMAN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/25/2024
Last Update Date: 08/04/2026
Certification Date: 08/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1620 FM 3344
JACKSBORO TX
76458-3127
US

IV. Provider business mailing address

1620 FM 3344
JACKSBORO TX
76458-3127
US

V. Phone/Fax

Practice location:
  • Phone: 940-567-2272
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number1051609
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: