Provider Demographics
NPI:1265636724
Name:HORTON, MARTHA CAROL (LPN)
Entity Type:Individual
Prefix:
First Name:MARTHA
Middle Name:CAROL
Last Name:HORTON
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8406C SHALLOWCREEK RD
Mailing Address - Street 2:
Mailing Address - City:LIVERPOOL
Mailing Address - State:NY
Mailing Address - Zip Code:13090-1320
Mailing Address - Country:US
Mailing Address - Phone:315-622-2262
Mailing Address - Fax:
Practice Address - Street 1:8406C SHALLOWCREEK RD
Practice Address - Street 2:
Practice Address - City:LIVERPOOL
Practice Address - State:NY
Practice Address - Zip Code:13090-1320
Practice Address - Country:US
Practice Address - Phone:315-622-2262
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY098129-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02126983Medicaid