Provider Demographics
NPI:1669085957
Name:MARTIN, MARY ELOISE (RN,BSN)
Entity type:Individual
Prefix:MRS
First Name:MARY
Middle Name:ELOISE
Last Name:MARTIN
Suffix:
Gender:F
Credentials:RN,BSN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:490 FARM ROAD 1735
Mailing Address - Street 2:
Mailing Address - City:MOUNT PLEASANT
Mailing Address - State:TX
Mailing Address - Zip Code:75455-8250
Mailing Address - Country:US
Mailing Address - Phone:903-563-4167
Mailing Address - Fax:
Practice Address - Street 1:516 E NIZHONI BLVD
Practice Address - Street 2:
Practice Address - City:GALLUP
Practice Address - State:NM
Practice Address - Zip Code:87301-5748
Practice Address - Country:US
Practice Address - Phone:505-722-1000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-26
Last Update Date:2020-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX909730163WM0705X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WM0705XNursing Service ProvidersRegistered NurseMedical-Surgical