Provider Demographics
NPI:1548823420
Name:DREW, MARTHA LYNN (LPN)
Entity type:Individual
Prefix:
First Name:MARTHA
Middle Name:LYNN
Last Name:DREW
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:MARTIE
Other - Middle Name:LYNN
Other - Last Name:KELLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPN
Mailing Address - Street 1:3101 MOLLY BROWN LANE
Mailing Address - Street 2:
Mailing Address - City:GREEN DAY
Mailing Address - State:WI
Mailing Address - Zip Code:54313
Mailing Address - Country:US
Mailing Address - Phone:920-784-5583
Mailing Address - Fax:
Practice Address - Street 1:3101 MOLLY BROWN LANE
Practice Address - Street 2:
Practice Address - City:GREEN DAY
Practice Address - State:WI
Practice Address - Zip Code:54313
Practice Address - Country:US
Practice Address - Phone:920-784-5583
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-17
Last Update Date:2019-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI318744164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse