Healthcare Provider Details

I. General information

NPI: 1457274482
Provider Name (Legal Business Name): MADISON NICOLE SHRADER-BOSCH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

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

III. Provider practice location address

508 W 6TH AVE STE 104
SPOKANE WA
99204-2738
US

IV. Provider business mailing address

12125 E NUNN RD
ATHOL ID
83801-9308
US

V. Phone/Fax

Practice location:
  • Phone: 509-455-9345
  • Fax:
Mailing address:
  • Phone: 208-610-5217
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberIR.61283386
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: