Provider Demographics
NPI:1619567799
Name:MARTIN, MELVIA SUE ANN (LPN)
Entity Type:Individual
Prefix:
First Name:MELVIA
Middle Name:SUE ANN
Last Name:MARTIN
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 1:6014 NW 16TH ST
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73127-2604
Mailing Address - Country:US
Mailing Address - Phone:405-706-3362
Mailing Address - Fax:
Practice Address - Street 1:6014 NW 16TH ST
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73127-2604
Practice Address - Country:US
Practice Address - Phone:405-706-3362
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-22
Last Update Date:2021-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK56727164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse