Basic Information
| Provider Information | |||||||||
| NPI: | 1689306854 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TREACY | ||||||||
| FirstName: | MADISON | ||||||||
| MiddleName: | RAE | ||||||||
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| Credential: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1557 PINE MARSH LOOP | ||||||||
| Address2: | |||||||||
| City: | SAINT CLOUD | ||||||||
| State: | FL | ||||||||
| PostalCode: | 347717407 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4074465350 | ||||||||
| FaxNumber: | 4079603009 | ||||||||
| Practice Location | |||||||||
| Address1: | 1557 PINE MARSH LOOP | ||||||||
| Address2: | |||||||||
| City: | SAINT CLOUD | ||||||||
| State: | FL | ||||||||
| PostalCode: | 347717407 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4074465350 | ||||||||
| FaxNumber: | 4079603009 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/27/2022 | ||||||||
| LastUpdateDate: | 06/27/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 06/27/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106S00000X | Y |
No ID Information.