Provider Demographics
NPI:1801489802
Name:MADDY, MAUDE
Entity type:Individual
Prefix:
First Name:MAUDE
Middle Name:
Last Name:MADDY
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 1:868 JOHN LANE RD
Mailing Address - Street 2:
Mailing Address - City:COOL RIDGE
Mailing Address - State:WV
Mailing Address - Zip Code:25825-9538
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:868 JOHN LANE RD
Practice Address - Street 2:
Practice Address - City:COOL RIDGE
Practice Address - State:WV
Practice Address - Zip Code:25825-9538
Practice Address - Country:US
Practice Address - Phone:304-787-3913
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-19
Last Update Date:2021-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker