Provider Demographics
NPI:1174678817
Name:MADRID, KATHLEEN MARTINA (L MT #505)
Entity Type:Individual
Prefix:MS
First Name:KATHLEEN
Middle Name:MARTINA
Last Name:MADRID
Suffix:
Gender:F
Credentials:L MT #505
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 414
Mailing Address - Street 2:HCR 77 BOX F9
Mailing Address - City:OJO CALIENTE
Mailing Address - State:NM
Mailing Address - Zip Code:87549-0414
Mailing Address - Country:US
Mailing Address - Phone:505-747-9798
Mailing Address - Fax:505-747-9798
Practice Address - Street 1:1167A HIGHWAY 554
Practice Address - Street 2:
Practice Address - City:EL RITO
Practice Address - State:NM
Practice Address - Zip Code:87530-0805
Practice Address - Country:US
Practice Address - Phone:505-581-0033
Practice Address - Fax:505-581-0034
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NML.M.T. #505174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist