Provider Demographics
NPI:1013776921
Name:MARTIN, ALYSSA CORI
Entity Type:Individual
Prefix:
First Name:ALYSSA
Middle Name:CORI
Last Name:MARTIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 Q ST NW # B
Mailing Address - Street 2:
Mailing Address - City:ARDMORE
Mailing Address - State:OK
Mailing Address - Zip Code:73401-4406
Mailing Address - Country:US
Mailing Address - Phone:580-341-8451
Mailing Address - Fax:
Practice Address - Street 1:10 Q ST NW # B
Practice Address - Street 2:
Practice Address - City:ARDMORE
Practice Address - State:OK
Practice Address - Zip Code:73401-4406
Practice Address - Country:US
Practice Address - Phone:580-341-8451
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-03-14
Last Update Date:2024-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist