Provider Demographics
NPI:1922353309
Name:CHANDLER, MARTINA (CR, LMT)
Entity Type:Individual
Prefix:
First Name:MARTINA
Middle Name:
Last Name:CHANDLER
Suffix:
Gender:F
Credentials:CR, LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1519 NW SMITH AVE
Mailing Address - Street 2:
Mailing Address - City:LAWTON
Mailing Address - State:OK
Mailing Address - Zip Code:73507-2648
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1519 NW SMITH AVE
Practice Address - Street 2:
Practice Address - City:LAWTON
Practice Address - State:OK
Practice Address - Zip Code:73507-2648
Practice Address - Country:US
Practice Address - Phone:580-583-2739
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-20
Last Update Date:2012-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK173C00000X
TXMT113631225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
No173C00000XOther Service ProvidersReflexologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK616546600OtherDOL