Provider Demographics
NPI:1174843809
Name:CLEM, MARTHA SUSAN (RN,WCC)
Entity Type:Individual
Prefix:MS
First Name:MARTHA
Middle Name:SUSAN
Last Name:CLEM
Suffix:
Gender:F
Credentials:RN,WCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 FREEDOM WAY
Mailing Address - Street 2:950 15TH STREET 4A 149A
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30904-6258
Mailing Address - Country:US
Mailing Address - Phone:706-733-0188
Mailing Address - Fax:
Practice Address - Street 1:1 FREEDOM WAY
Practice Address - Street 2:950 15TH STREET 4A 149A
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30904-6258
Practice Address - Country:US
Practice Address - Phone:706-733-0188
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-06-04
Last Update Date:2010-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN170229163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse