Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 101YP2500X | Professional Counselor | 2004008789 | MO |
Y | 363LA2200X | Nurse Practitioner - Adult Health | 2005035596 | MO |
N | 363LP2300X | Nurse Practitioner - Primary Care | 2005035596 | MO |
NPI | 1063403418 |
---|---|
Provider Name | Kathy Martin |
First Address | Joplin, MO 64801-2538 |
Second Address | Joplin, MO 64801 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 03/11/2005 |
Last Update Date | 25/06/2018 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
1003149261 | (05) | MO |
20048789 | (05) | MO |
244 | (05) | KS |