Provider Demographics
NPI:1679746689
Name:WING, MARTHA ANN (BA)
Entity Type:Individual
Prefix:
First Name:MARTHA
Middle Name:ANN
Last Name:WING
Suffix:
Gender:F
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:648 FLORIDA AVE
Mailing Address - Street 2:
Mailing Address - City:PANAMA CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32401-6311
Mailing Address - Country:US
Mailing Address - Phone:850-769-6001
Mailing Address - Fax:850-769-6003
Practice Address - Street 1:648 FLORIDA AVE
Practice Address - Street 2:
Practice Address - City:PANAMA CITY
Practice Address - State:FL
Practice Address - Zip Code:32401-6311
Practice Address - Country:US
Practice Address - Phone:850-769-6001
Practice Address - Fax:850-769-6003
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-10
Last Update Date:2008-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL769053300Medicaid