Provider Demographics
NPI:1336789973
Name:MARTIN, ELIZABETH JONELLE
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:JONELLE
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 1:801 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:INDEPENDENCE
Mailing Address - State:MO
Mailing Address - Zip Code:64050-2829
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:201 NW R D MIZE RD
Practice Address - Street 2:
Practice Address - City:BLUE SPRINGS
Practice Address - State:MO
Practice Address - Zip Code:64014-2513
Practice Address - Country:US
Practice Address - Phone:816-228-5900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-12
Last Update Date:2020-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS11-06340225100000X
MO2019044107225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist