Provider Demographics
NPI:1134764798
Name:WHITE, MADALYN BROOKE (NP)
Entity type:Individual
Prefix:
First Name:MADALYN
Middle Name:BROOKE
Last Name:WHITE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5659 PARKWAY DR STE 210
Mailing Address - Street 2:
Mailing Address - City:GLOUCESTER
Mailing Address - State:VA
Mailing Address - Zip Code:23061-3792
Mailing Address - Country:US
Mailing Address - Phone:804-210-1025
Mailing Address - Fax:804-210-1029
Practice Address - Street 1:5659 PARKWAY DR STE 210
Practice Address - Street 2:
Practice Address - City:GLOUCESTER
Practice Address - State:VA
Practice Address - Zip Code:23061-3792
Practice Address - Country:US
Practice Address - Phone:804-210-1025
Practice Address - Fax:804-210-1029
Is Sole Proprietor?:No
Enumeration Date:2019-11-07
Last Update Date:2021-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024178442363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily