Provider Demographics
NPI:1932653698
Name:MARTIN, EVELYN TERESA (RN)
Entity Type:Individual
Prefix:MS
First Name:EVELYN
Middle Name:TERESA
Last Name:MARTIN
Suffix:
Gender:F
Credentials:RN
Other - Prefix:MS
Other - First Name:EVELYN
Other - Middle Name:TERESA
Other - Last Name:MUETH MARTIN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:RN
Mailing Address - Street 1:309 WABASH AVE
Mailing Address - Street 2:
Mailing Address - City:BELLEVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62220-3843
Mailing Address - Country:US
Mailing Address - Phone:618-806-8601
Mailing Address - Fax:
Practice Address - Street 1:309 WABASH AVE
Practice Address - Street 2:
Practice Address - City:BELLEVILLE
Practice Address - State:IL
Practice Address - Zip Code:62220-3843
Practice Address - Country:US
Practice Address - Phone:618-806-8601
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-11
Last Update Date:2016-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041178086163W00000X
MO077284163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse