Provider Demographics
NPI:1497932404
Name:MOORE, MARTHA SUSAN (RN)
Entity Type:Individual
Prefix:MRS
First Name:MARTHA
Middle Name:SUSAN
Last Name:MOORE
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:314 E OWEN K GARRIOTT RD
Mailing Address - Street 2:
Mailing Address - City:ENID
Mailing Address - State:OK
Mailing Address - Zip Code:73701
Mailing Address - Country:US
Mailing Address - Phone:580-233-8315
Mailing Address - Fax:580-233-9441
Practice Address - Street 1:314 E OWEN K GARRIOTT RD
Practice Address - Street 2:
Practice Address - City:ENID
Practice Address - State:OK
Practice Address - Zip Code:73701
Practice Address - Country:US
Practice Address - Phone:580-233-8315
Practice Address - Fax:580-233-9441
Is Sole Proprietor?:No
Enumeration Date:2008-01-22
Last Update Date:2008-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKR0058176163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse