Provider Demographics
NPI:1679155790
Name:YATES, MADISON NICOLE (DPT)
Entity type:Individual
Prefix:DR
First Name:MADISON
Middle Name:NICOLE
Last Name:YATES
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 LAKE VIEW DR E
Mailing Address - Street 2:
Mailing Address - City:PINEHURST
Mailing Address - State:NC
Mailing Address - Zip Code:28374-6930
Mailing Address - Country:US
Mailing Address - Phone:256-394-0660
Mailing Address - Fax:
Practice Address - Street 1:2050 SCENIC HWY N STE A8
Practice Address - Street 2:
Practice Address - City:SNELLVILLE
Practice Address - State:GA
Practice Address - Zip Code:30078-2688
Practice Address - Country:US
Practice Address - Phone:678-344-7197
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-27
Last Update Date:2021-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP19302225100000X
GACP008278T225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist