Provider Demographics
NPI:1811598717
Name:MARTIN, BOBBIE JO
Entity Type:Individual
Prefix:
First Name:BOBBIE
Middle Name:JO
Last Name:MARTIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:117 E RAY FINE BLVD
Mailing Address - Street 2:
Mailing Address - City:ROLAND
Mailing Address - State:OK
Mailing Address - Zip Code:74954-5198
Mailing Address - Country:US
Mailing Address - Phone:918-427-6644
Mailing Address - Fax:
Practice Address - Street 1:117 E RAY FINE BLVD
Practice Address - Street 2:
Practice Address - City:ROLAND
Practice Address - State:OK
Practice Address - Zip Code:74954-5198
Practice Address - Country:US
Practice Address - Phone:918-427-6644
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-06
Last Update Date:2020-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR49006164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse