MEDICARE: EMILY NICOLE VANDERMADEN DPT

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	225100000X	Physical Therapist	05011764A	IN

General Provider Information

NPI Number	:	1821464603
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	EMILY NICOLE VANDERMADEN DPT

Provider Business Mailing Address
First Line	:	9823 AUBURN RD
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46825-2347
Country	:	US
Telephone Number	:	260-497-7191
Fax Number	:

Provider Business Practice Location Address
First Line	:	9823 AUBURN RD
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46825-2347
Country	:	US
Telephone Number	:	260-497-7191
Fax Number	:

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

Provider Enumeration Date	:	08/17/2015
Last Update Date	:	09/22/2025

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