Provider Demographics
NPI:1992024202
Name:MARTIN, THERESA ANNE (RN)
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:ANNE
Last Name:MARTIN
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1450 DARTMOUTH DR
Mailing Address - Street 2:
Mailing Address - City:SAINT CHARLES
Mailing Address - State:MO
Mailing Address - Zip Code:63303-3659
Mailing Address - Country:US
Mailing Address - Phone:636-395-7073
Mailing Address - Fax:636-395-7073
Practice Address - Street 1:1450 DARTMOUTH DR
Practice Address - Street 2:
Practice Address - City:SAINT CHARLES
Practice Address - State:MO
Practice Address - Zip Code:63303-3659
Practice Address - Country:US
Practice Address - Phone:636-395-7073
Practice Address - Fax:636-395-7073
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-26
Last Update Date:2010-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2007002928163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse