Provider Demographics
NPI:1861981235
Name:MARTIN, JUDIE ANGELA
Entity type:Individual
Prefix:
First Name:JUDIE
Middle Name:ANGELA
Last Name:MARTIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:629 W SHEPHERD DR
Mailing Address - Street 2:
Mailing Address - City:MUSTANG
Mailing Address - State:OK
Mailing Address - Zip Code:73064-3205
Mailing Address - Country:US
Mailing Address - Phone:405-202-6089
Mailing Address - Fax:
Practice Address - Street 1:13909 TECHNOLOGY DR STE A1
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73134-1060
Practice Address - Country:US
Practice Address - Phone:405-202-6089
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-01
Last Update Date:2018-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator