=====================================================
General NPI Number Information
=====================================================
NPI Number | 1538651104
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SPRING GENNAY MADDOX CNM, WHNP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/31/2018
-----------------------------------------------------
Last Update Date | 10/19/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 18400 CHESTNUT AVE
-----------------------------------------------------
City | TUOLUMNE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95379
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 209-928-4907
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 897
-----------------------------------------------------
City | TUOLUMNE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95379-0897
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 209-928-4907
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 367A00000X
-----------------------------------------------------
Taxonomy Name | Advanced Practice Midwife
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------