Healthcare Provider Details

I. General information

NPI: 1275120446
Provider Name (Legal Business Name): ELENA MADERA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/22/2020
Last Update Date: 09/12/2022
Certification Date: 09/12/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

721 W MAPLE ST
RAWLINS WY
82301-5447
US

IV. Provider business mailing address

PO BOX 1056
RAWLINS WY
82301-1056
US

V. Phone/Fax

Practice location:
  • Phone: 307-324-7156
  • Fax: 307-328-1651
Mailing address:
  • Phone: 307-324-7156
  • Fax: 307-328-1651

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberPPC-1287
License Number StateWY
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: