Basic Information
| Provider Information | |||||||||
| NPI: | 1255055745 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DRAKE | ||||||||
| FirstName: | MADISEN | ||||||||
| MiddleName: | ALEXANDRIA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 497 WYOMING AVE | ||||||||
| Address2: | |||||||||
| City: | FAIRFIELD | ||||||||
| State: | OH | ||||||||
| PostalCode: | 450141677 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5138028405 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3333 BURNET AVE | ||||||||
| Address2: | |||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452293026 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5136364200 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/28/2022 | ||||||||
| LastUpdateDate: | 11/09/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 11/09/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0200X | 0032625 | OH | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.