Provider Demographics
NPI:1245990811
Name:WASHINGTON, MARTHA RIVERS
Entity type:Individual
Prefix:
First Name:MARTHA
Middle Name:RIVERS
Last Name:WASHINGTON
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 1:11502 RIVERSTONE WAY
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32218-9506
Mailing Address - Country:US
Mailing Address - Phone:904-236-2808
Mailing Address - Fax:
Practice Address - Street 1:11502 RIVERSTONE WAY
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32218-9506
Practice Address - Country:US
Practice Address - Phone:904-236-2808
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-23
Last Update Date:2021-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL693649196Medicaid