Provider Demographics
NPI:1992141121
Name:STEWART, MARTHA ELAINE (MA 60351243)
Entity type:Individual
Prefix:
First Name:MARTHA ELAINE
Middle Name:
Last Name:STEWART
Suffix:
Gender:F
Credentials:MA 60351243
Other - Prefix:
Other - First Name:MARTHA
Other - Middle Name:ELAINE
Other - Last Name:STEWART
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:835 N 45TH AVE
Mailing Address - Street 2:
Mailing Address - City:RIDGEFIELD
Mailing Address - State:WA
Mailing Address - Zip Code:98642-5322
Mailing Address - Country:US
Mailing Address - Phone:360-666-7722
Mailing Address - Fax:
Practice Address - Street 1:835 N 45TH AVE
Practice Address - Street 2:
Practice Address - City:RIDGEFIELD
Practice Address - State:WA
Practice Address - Zip Code:98642-5322
Practice Address - Country:US
Practice Address - Phone:360-666-7722
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-15
Last Update Date:2013-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA 60351243171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor