Provider Demographics
NPI:1194133363
Name:STALEY, MADELINE K (FNP-BC)
Entity type:Individual
Prefix:
First Name:MADELINE
Middle Name:K
Last Name:STALEY
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:MADELINE
Other - Middle Name:ROSE
Other - Last Name:KLIM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3452 ANDERSON HWY
Mailing Address - Street 2:SUITE D
Mailing Address - City:POWHATAN
Mailing Address - State:VA
Mailing Address - Zip Code:23139-5845
Mailing Address - Country:US
Mailing Address - Phone:804-285-6050
Mailing Address - Fax:804-598-2481
Practice Address - Street 1:3452 ANDERSON HWY STE D
Practice Address - Street 2:POWHATAN MEDICAL ASSOCIATES
Practice Address - City:POWHATAN
Practice Address - State:VA
Practice Address - Zip Code:23139-5845
Practice Address - Country:US
Practice Address - Phone:804-285-6050
Practice Address - Fax:804-598-2481
Is Sole Proprietor?:No
Enumeration Date:2014-07-31
Last Update Date:2020-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024171775363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAC09633OtherGROUP PTAN