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General NPI Number Information
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NPI Number | 1619760782
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Entity Type | Individual
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Provider Name | MADELINE GRACE CLEMENTS
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Gender | Female
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Dates
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Enumeration Date | 05/22/2025
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Last Update Date | 08/13/2025
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Provider Practice Location Address
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Address Line | 4035 MIMOSA DR
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City | COLUMBUS
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State | IN
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Zip | 47201-7200
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Country | US
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Telephone | 831-786-5904
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Fax | 317-867-5321
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Provider Business Mailing Address
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Address Line | PO BOX 781076
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City | DETROIT
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State | MI
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Zip | 48278-1076
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Country | US
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Telephone | 317-528-4800
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Fax | 317-865-1479
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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 | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | 10004926A
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License Number State | IN
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