Provider Demographics
NPI:1902095193
Name:MARTIN, MARY ELIZABETH (RN, BS,BSN)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:ELIZABETH
Last Name:MARTIN
Suffix:
Gender:F
Credentials:RN, BS,BSN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 507
Mailing Address - Street 2:
Mailing Address - City:SCIOTA
Mailing Address - State:PA
Mailing Address - Zip Code:18354-0507
Mailing Address - Country:US
Mailing Address - Phone:570-992-6300
Mailing Address - Fax:570-402-2900
Practice Address - Street 1:BUSINESS ROUTE 209 AND BOSSARDSVILLE ROAD
Practice Address - Street 2:
Practice Address - City:SCIOTA
Practice Address - State:PA
Practice Address - Zip Code:18354
Practice Address - Country:US
Practice Address - Phone:570-992-6300
Practice Address - Fax:570-402-2900
Is Sole Proprietor?:No
Enumeration Date:2007-10-24
Last Update Date:2007-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARN243814L163WG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WG0600XNursing Service ProvidersRegistered NurseGerontology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0016671410002Medicaid
PA0016671410002Medicaid