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General NPI Number Information
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NPI Number | 1396276663
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Entity Type | Individual
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Provider Name | LEA NICHOLE MADDOX D.O.
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Gender | Female
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Dates
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Enumeration Date | 03/27/2017
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Last Update Date | 07/10/2024
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Provider Practice Location Address
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Address Line | 15855 19 MILE RD
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City | CLINTON TOWNSHIP
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State | MI
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Zip | 48038-3504
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Country | US
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Telephone | 319-533-3200
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Fax |
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Provider Business Mailing Address
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Address Line | 1118 ROSS CLARK CIR STE 600
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City | DOTHAN
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State | AL
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Zip | 36301-3042
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Country | US
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Telephone | 334-793-3900
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Fax | 334-793-5227
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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 | 390200000X
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Taxonomy Name | Student in an Organized Health Care Education/Training Program
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 207VX0000X
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Taxonomy Name | Obstetrics Physician
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License Number | 2863
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License Number State | AL
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