Provider Demographics
NPI:1952325284
Name:MARTIN, MANDY MARIE (ATC)
Entity Type:Individual
Prefix:MS
First Name:MANDY
Middle Name:MARIE
Last Name:MARTIN
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 637
Mailing Address - Street 2:
Mailing Address - City:NEW ALBANY
Mailing Address - State:MS
Mailing Address - Zip Code:38652-0637
Mailing Address - Country:US
Mailing Address - Phone:662-296-4808
Mailing Address - Fax:
Practice Address - Street 1:104 CHRYSTAL PLAZA DR
Practice Address - Street 2:
Practice Address - City:NEW ALBANY
Practice Address - State:MS
Practice Address - Zip Code:38652-3198
Practice Address - Country:US
Practice Address - Phone:662-534-4445
Practice Address - Fax:662-534-9449
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSATO3362255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer