Provider Demographics
NPI:1154927218
Name:BUNDRUM, MADISON SHANKS
Entity type:Individual
Prefix:
First Name:MADISON
Middle Name:SHANKS
Last Name:BUNDRUM
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 1:379 BARRINGTON CIR
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:AL
Mailing Address - Zip Code:36250-7216
Mailing Address - Country:US
Mailing Address - Phone:256-282-0002
Mailing Address - Fax:
Practice Address - Street 1:912 SNOW ST
Practice Address - Street 2:
Practice Address - City:OXFORD
Practice Address - State:AL
Practice Address - Zip Code:36203-1214
Practice Address - Country:US
Practice Address - Phone:256-237-1001
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-04
Last Update Date:2023-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-171297163W00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
No163W00000XNursing Service ProvidersRegistered Nurse