Basic Information
| Provider Information | |||||||||
| NPI: | 1710636279 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ZENK | ||||||||
| FirstName: | MADISON | ||||||||
| MiddleName: | CLAIRE | ||||||||
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| OtherLastName: | ZENK | ||||||||
| OtherFirstName: | MADDIE | ||||||||
| OtherMiddleName: | CLAIRE | ||||||||
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| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 617 S 31ST ST APT 102 | ||||||||
| Address2: | |||||||||
| City: | OMAHA | ||||||||
| State: | NE | ||||||||
| PostalCode: | 681051445 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9703246088 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1000 BLYTHE BLVD. | ||||||||
| Address2: | 4TH FLOOR, MEB | ||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282035812 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7043816800 | ||||||||
| FaxNumber: | 7043816841 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/22/2022 | ||||||||
| LastUpdateDate: | 03/22/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 03/22/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | Y | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.