Provider Demographics
NPI:1689895864
Name:MARTHA A. BRECKENRIDGE
Entity Type:Organization
Organization Name:MARTHA A. BRECKENRIDGE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:MARTHA
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:BRECKENRIDGE
Authorized Official - Suffix:
Authorized Official - Credentials:WHNP
Authorized Official - Phone:214-724-3723
Mailing Address - Street 1:PO BOX 346
Mailing Address - Street 2:
Mailing Address - City:DESOTO
Mailing Address - State:TX
Mailing Address - Zip Code:75123-0346
Mailing Address - Country:US
Mailing Address - Phone:469-567-1234
Mailing Address - Fax:972-224-5403
Practice Address - Street 1:1505 SANDSTONE CT
Practice Address - Street 2:
Practice Address - City:DESOTO
Practice Address - State:TX
Practice Address - Zip Code:75115-7841
Practice Address - Country:US
Practice Address - Phone:214-724-3723
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-02
Last Update Date:2023-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251E00000X, 320900000X
TX242859363LW0102X, 363LX0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's HealthGroup - Multi-Specialty
No251E00000XAgenciesHome HealthGroup - Multi-Specialty
No320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental DisabilitiesGroup - Multi-Specialty
No363LX0001XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerObstetrics & GynecologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00X578Medicare UPIN
TX8F5007Medicare PIN