Provider Demographics
NPI:1861232142
Name:MADDOX, MANDIE L (FNP)
Entity type:Individual
Prefix:
First Name:MANDIE
Middle Name:L
Last Name:MADDOX
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16597 18B RD
Mailing Address - Street 2:
Mailing Address - City:CULVER
Mailing Address - State:IN
Mailing Address - Zip Code:46511-9733
Mailing Address - Country:US
Mailing Address - Phone:574-339-6072
Mailing Address - Fax:
Practice Address - Street 1:2855 MILLER DR STE 205
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:IN
Practice Address - Zip Code:46563-8093
Practice Address - Country:US
Practice Address - Phone:574-941-1080
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-25
Last Update Date:2024-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28185360A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily