MEDICARE: ALTAGRACE MADISTIN

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	163WH0200X	Home Health Registered Nurse	RN9490290	FL

General Provider Information

NPI Number	:	1467047027
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ALTAGRACE MADISTIN

Provider Business Mailing Address
First Line	:	3939 S CONGRESS AVE STE 106
Second Line	:
City	:	LAKE WORTH
State	:	FL
Zip	:	33461-4119
Country	:	US
Telephone Number	:	561-907-9522
Fax Number	:

Provider Business Practice Location Address
First Line	:	3939 S CONGRESS AVE STE 106
Second Line	:
City	:	LAKE WORTH
State	:	FL
Zip	:	33461-4119
Country	:	US
Telephone Number	:	561-907-9522
Fax Number	:

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

Provider Enumeration Date	:	03/05/2021
Last Update Date	:	03/05/2021

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Directions to “ ALTAGRACE MADISTIN ” Practice Location

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