Provider Demographics
NPI:1407603178
Name:WELLBORN, MADELINE
Entity type:Individual
Prefix:
First Name:MADELINE
Middle Name:
Last Name:WELLBORN
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 1:7 ONONDAGA ST
Mailing Address - Street 2:
Mailing Address - City:SKANEATELES
Mailing Address - State:NY
Mailing Address - Zip Code:13152-1313
Mailing Address - Country:US
Mailing Address - Phone:315-739-4459
Mailing Address - Fax:
Practice Address - Street 1:1901 N GRANT ST APT 425
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80203-1253
Practice Address - Country:US
Practice Address - Phone:318-834-0158
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-01
Last Update Date:2024-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO86293321133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered