MEDICARE: DOMINIQUE MADISON

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	374J00000X	Doula

General Provider Information

NPI Number	:	1568092310
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DOMINIQUE MADISON

Provider Business Mailing Address
First Line	:	2223 N SHERMAN BLVD
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53208-1215
Country	:	US
Telephone Number	:	414-750-0848
Fax Number	:

Provider Business Practice Location Address
First Line	:	2223 N SHERMAN BLVD
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53208-1215
Country	:	US
Telephone Number	:	414-750-0848
Fax Number	:

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

Provider Enumeration Date	:	01/21/2020
Last Update Date	:	01/21/2020

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Directions to “ DOMINIQUE MADISON ” Practice Location

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