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General NPI Number Information
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NPI Number | 1063004158
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Entity Type | Individual
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Provider Name | MADISEN TAYLER STACKS
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Gender | Female
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Dates
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Enumeration Date | 02/09/2021
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Last Update Date | 08/24/2021
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Provider Practice Location Address
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Address Line | 503 MAIN ST STE C
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City | LAKE DALLAS
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State | TX
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Zip | 75065-2878
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Country | US
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Telephone | 940-535-5296
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Fax |
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Provider Business Mailing Address
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Address Line | 503 MAIN ST STE C
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City | LAKE DALLAS
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State | TX
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Zip | 75065-2878
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Country | US
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Telephone | 832-367-8843
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number | 1029434
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License Number State | TX
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