1902315567 NPI number — MRS. NICOLE LYNN MARTY M.S. SLP

Table of content: MRS. NICOLE LYNN MARTY M.S. SLP (NPI 1902315567)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1902315567 NPI number — MRS. NICOLE LYNN MARTY M.S. SLP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MARTY
Provider First Name:
NICOLE
Provider Middle Name:
LYNN
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
M.S. SLP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1902315567
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/27/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
205 S ENGLEWOOD DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
METAMORA
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
61548-8781
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
309-367-4901
Provider Business Mailing Address Fax Number:
309-367-4905

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
508 E WALNUT ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WASHBURN
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
61570-7539
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
309-248-7221
Provider Business Practice Location Address Fax Number:
309-248-7518
Provider Enumeration Date:
09/27/2017

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 235Z00000X , with the licence number:  146006221 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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