MEDICARE: MADISON WINDLEY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	164W00000X	Licensed Practical Nurse	13714215-3101	UT

General Provider Information

NPI Number	:	1205675188
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MADISON WINDLEY

Provider Business Mailing Address
First Line	:	2392 W JADE WAY
Second Line	:
City	:	WEST HAVEN
State	:	UT
Zip	:	84401-8612
Country	:	US
Telephone Number	:	208-339-2094
Fax Number	:

Provider Business Practice Location Address
First Line	:	2392 W JADE WAY
Second Line	:
City	:	WEST HAVEN
State	:	UT
Zip	:	84401-8612
Country	:	US
Telephone Number	:	208-339-2094
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/21/2024
Last Update Date	:	05/21/2024

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Directions to “ MADISON WINDLEY ” Practice Location

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