Provider Demographics
NPI:1932353455
Name:MARTIN, MARY ELIZABETH
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:ELIZABETH
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 1:2930 CO.RD.4003
Mailing Address - Street 2:
Mailing Address - City:HOLTS SUMMIT
Mailing Address - State:MO
Mailing Address - Zip Code:65043
Mailing Address - Country:US
Mailing Address - Phone:573-295-6684
Mailing Address - Fax:573-295-6684
Practice Address - Street 1:2930 COUNTY ROAD 4002
Practice Address - Street 2:
Practice Address - City:HOLTS SUMMIT
Practice Address - State:MO
Practice Address - Zip Code:65043-2079
Practice Address - Country:US
Practice Address - Phone:573-295-6684
Practice Address - Fax:573-295-6684
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-11
Last Update Date:2008-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes177F00000XOther Service ProvidersLodging