Provider Demographics
NPI:1548985930
Name:STANFORD, MARTAVIA (LABORATORY DIRECTOR)
Entity type:Individual
Prefix:
First Name:MARTAVIA
Middle Name:
Last Name:STANFORD
Suffix:
Gender:F
Credentials:LABORATORY DIRECTOR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 BISHOPS WAY STE 165
Mailing Address - Street 2:
Mailing Address - City:BROOKFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53005-6249
Mailing Address - Country:US
Mailing Address - Phone:414-355-5525
Mailing Address - Fax:414-240-4595
Practice Address - Street 1:120 BISHOPS WAY STE 165
Practice Address - Street 2:
Practice Address - City:BROOKFIELD
Practice Address - State:WI
Practice Address - Zip Code:53005-6249
Practice Address - Country:US
Practice Address - Phone:414-355-5525
Practice Address - Fax:414-240-4595
Is Sole Proprietor?:No
Enumeration Date:2022-10-07
Last Update Date:2022-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YP1600X, 372600000X, 374U00000X, 376J00000X
WI52D2261520247ZC0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247ZC0005XTechnologists, Technicians & Other Technical Service ProvidersTechnician, PathologyClinical Laboratory Director, Non-physician
No101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoral
No372600000XNursing Service Related ProvidersAdult Companion
No374U00000XNursing Service Related ProvidersHome Health Aide
No376J00000XNursing Service Related ProvidersHomemaker
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI52D2261520OtherCLIA STATE OF WISCONSIN