MEDICARE: AMANDA D MADISON FNP

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	363LF0000X	Family Nurse Practitioner	AP125963	TX

General Provider Information

NPI Number	:	1548661556
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	AMANDA D MADISON FNP

Provider Business Mailing Address
First Line	:	2941 TIMBER CREEK TRL
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76118-7321
Country	:	US
Telephone Number	:	469-450-2243
Fax Number	:	469-621-4549

Provider Business Practice Location Address
First Line	:	4512 RALPH LN
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75227-1845
Country	:	US
Telephone Number	:	972-243-7903
Fax Number	:	972-243-7905

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

Provider Enumeration Date	:	09/09/2014
Last Update Date	:	09/09/2014

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