Provider Demographics
NPI:1336874684
Name:MIMS, MADISON ALLEN (WHNP-BC)
Entity type:Individual
Prefix:
First Name:MADISON
Middle Name:ALLEN
Last Name:MIMS
Suffix:
Gender:F
Credentials:WHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10815 MORTONS XING
Mailing Address - Street 2:
Mailing Address - City:ALPHARETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30022-5626
Mailing Address - Country:US
Mailing Address - Phone:478-363-4224
Mailing Address - Fax:
Practice Address - Street 1:1015 MANSELL RD
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:GA
Practice Address - Zip Code:30076-1507
Practice Address - Country:US
Practice Address - Phone:770-462-0313
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-20
Last Update Date:2022-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN286470363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health