Provider Demographics
NPI:1376669002
Name:MARTIN, BEVERLY ANN
Entity Type:Individual
Prefix:MRS
First Name:BEVERLY
Middle Name:ANN
Last Name:MARTIN
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 1:604 W PINE ST
Mailing Address - Street 2:
Mailing Address - City:MAHANOY CITY
Mailing Address - State:PA
Mailing Address - Zip Code:17948-2410
Mailing Address - Country:US
Mailing Address - Phone:570-773-3487
Mailing Address - Fax:
Practice Address - Street 1:604 W PINE ST
Practice Address - Street 2:
Practice Address - City:MAHANOY CITY
Practice Address - State:PA
Practice Address - Zip Code:17948-2410
Practice Address - Country:US
Practice Address - Phone:570-773-3487
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA9978794164W00000X, 390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered164W00000XNursing Service ProvidersLicensed Practical Nurse
Not Answered390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program