Provider Demographics
NPI:1578964847
Name:MARTIN, DEIDRE P (RPT)
Entity Type:Individual
Prefix:MS
First Name:DEIDRE
Middle Name:P
Last Name:MARTIN
Suffix:
Gender:F
Credentials:RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1500 DOGWOOD LN
Mailing Address - Street 2:
Mailing Address - City:FOLEY
Mailing Address - State:AL
Mailing Address - Zip Code:36535-2216
Mailing Address - Country:US
Mailing Address - Phone:251-968-6067
Mailing Address - Fax:
Practice Address - Street 1:1701 N ALSTON ST
Practice Address - Street 2:
Practice Address - City:FOLEY
Practice Address - State:AL
Practice Address - Zip Code:36535-2246
Practice Address - Country:US
Practice Address - Phone:251-943-7781
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-05
Last Update Date:2017-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility