Provider Demographics
NPI:1265539811
Name:MARTHA, MARY
Entity type:Individual
Prefix:MS
First Name:MARY
Middle Name:
Last Name:MARTHA
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 1:4534 SE ELLSWORTH AVE
Mailing Address - Street 2:
Mailing Address - City:LAWTON
Mailing Address - State:OK
Mailing Address - Zip Code:73501-8334
Mailing Address - Country:US
Mailing Address - Phone:580-357-5880
Mailing Address - Fax:
Practice Address - Street 1:4534 SE ELLSWORTH AVE
Practice Address - Street 2:
Practice Address - City:LAWTON
Practice Address - State:OK
Practice Address - Zip Code:73501-8334
Practice Address - Country:US
Practice Address - Phone:580-357-5880
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered376J00000XNursing Service Related ProvidersHomemaker
Not Answered385H00000XRespite Care FacilityRespite Care