Basic Information
| Provider Information | |||||||||
| NPI: | 1417358995 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MADISON | ||||||||
| FirstName: | ANGELIQUE | ||||||||
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| Credential: | FNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6701 PAW PAW AVE | ||||||||
| Address2: | |||||||||
| City: | COLOMA | ||||||||
| State: | MI | ||||||||
| PostalCode: | 490389519 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2694633000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 400 MEDICAL PARK DR | ||||||||
| Address2: | |||||||||
| City: | WATERVLIET | ||||||||
| State: | MI | ||||||||
| PostalCode: | 490989225 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2694633600 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/15/2014 | ||||||||
| LastUpdateDate: | 11/13/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 4704253993 | MI | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 1417358995 | 05 | MI | MEDICAID |