Provider Demographics
NPI:1891117685
Name:MARTIN, MARIE SHIRLEY
Entity Type:Individual
Prefix:MS
First Name:MARIE
Middle Name:SHIRLEY
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 1:220 W WILLOW ST
Mailing Address - Street 2:BLDG A
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70501-2837
Mailing Address - Country:US
Mailing Address - Phone:337-262-5616
Mailing Address - Fax:337-262-1310
Practice Address - Street 1:220 W WILLOW ST
Practice Address - Street 2:BLDG A
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70501-2837
Practice Address - Country:US
Practice Address - Phone:337-262-5616
Practice Address - Fax:337-262-1310
Is Sole Proprietor?:No
Enumeration Date:2014-01-13
Last Update Date:2014-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LARN123139163WC1500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC1500XNursing Service ProvidersRegistered NurseCommunity Health