Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 363L00000X | Nurse Practitioner | 2005035596 | MO |
NPI | 1003149261 |
---|---|
Provider Name | Mrs. Kathy Joan Martin |
First Address | Reeds Spring, MO 65737 |
Second Address | Reeds Spring, MO 65737 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 04/09/2009 |
Last Update Date | 24/07/2015 |