Provider Demographics
NPI:1821854365
Name:MARTIN, RAEGAN MACKENZIE
Entity Type:Individual
Prefix:
First Name:RAEGAN
Middle Name:MACKENZIE
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 1:2982 MADAMS CREEK RD
Mailing Address - Street 2:
Mailing Address - City:HINTON
Mailing Address - State:WV
Mailing Address - Zip Code:25951-7047
Mailing Address - Country:US
Mailing Address - Phone:304-716-5703
Mailing Address - Fax:
Practice Address - Street 1:2982 MADAMS CREEK RD
Practice Address - Street 2:
Practice Address - City:HINTON
Practice Address - State:WV
Practice Address - Zip Code:25951-7047
Practice Address - Country:US
Practice Address - Phone:304-716-5703
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-22
Last Update Date:2024-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant