Provider Demographics
NPI:1699292854
Name:CLISHAM, MADELINE (CRNP)
Entity type:Individual
Prefix:
First Name:MADELINE
Middle Name:
Last Name:CLISHAM
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:MADELINE
Other - Middle Name:
Other - Last Name:MARTIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:1787 SENTRY PKWY W STE 405
Mailing Address - Street 2:
Mailing Address - City:BLUE BELL
Mailing Address - State:PA
Mailing Address - Zip Code:19422-2239
Mailing Address - Country:US
Mailing Address - Phone:877-868-4827
Mailing Address - Fax:
Practice Address - Street 1:1787 SENTRY PKWY W STE 405
Practice Address - Street 2:
Practice Address - City:BLUE BELL
Practice Address - State:PA
Practice Address - Zip Code:19422-2239
Practice Address - Country:US
Practice Address - Phone:877-868-4827
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-28
Last Update Date:2022-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP017475363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology