Provider Demographics
NPI:1356103337
Name:PIEDRA, MADISON GRACE
Entity type:Individual
Prefix:
First Name:MADISON
Middle Name:GRACE
Last Name:PIEDRA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 ANTHEM AVE
Mailing Address - Street 2:
Mailing Address - City:DOTHAN
Mailing Address - State:AL
Mailing Address - Zip Code:36305-7372
Mailing Address - Country:US
Mailing Address - Phone:334-714-4403
Mailing Address - Fax:
Practice Address - Street 1:110 ANTHEM AVE
Practice Address - Street 2:
Practice Address - City:DOTHAN
Practice Address - State:AL
Practice Address - Zip Code:36305-7372
Practice Address - Country:US
Practice Address - Phone:334-714-4403
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-25
Last Update Date:2024-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program