1194133363 NPI number — MADELINE K STALEY FNP-BC

Table of content: MADELINE K STALEY FNP-BC (NPI 1194133363)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1194133363 NPI number — MADELINE K STALEY FNP-BC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
STALEY
Provider First Name:
MADELINE
Provider Middle Name:
K
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
FNP-BC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
KLIM
Provider Other First Name:
MADELINE
Provider Other Middle Name:
ROSE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1194133363
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/15/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3452 ANDERSON HWY
Provider Second Line Business Mailing Address:
SUITE D
Provider Business Mailing Address City Name:
POWHATAN
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
23139-5845
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
804-285-6050
Provider Business Mailing Address Fax Number:
804-598-2481

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3452 ANDERSON HWY STE D
Provider Second Line Business Practice Location Address:
POWHATAN MEDICAL ASSOCIATES
Provider Business Practice Location Address City Name:
POWHATAN
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
23139-5845
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
804-285-6050
Provider Business Practice Location Address Fax Number:
804-598-2481
Provider Enumeration Date:
07/31/2014

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: 363LF0000X , with the licence number:  0024171775 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: C09633 . This is a "GROUP PTAN" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".




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