1144006560 NPI number — MADELYN E BONEY NP

Table of content: MADELYN E BONEY NP (NPI 1144006560)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1144006560 NPI number — MADELYN E BONEY NP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BONEY
Provider First Name:
MADELYN
Provider Middle Name:
E
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
NP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1144006560
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/05/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 735044
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHICAGO
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60673-5044
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2219 GARFIELD ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TWO RIVERS
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
54241-2416
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
920-793-2281
Provider Business Practice Location Address Fax Number:
920-793-2281
Provider Enumeration Date:
09/01/2023

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363L00000X , with the licence number:  14467-033 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 100253059 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com