Provider Demographics
NPI:1063403418
Name:MARTIN, KATHY (MS)
Entity type:Individual
Prefix:
First Name:KATHY
Middle Name:
Last Name:MARTIN
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:315 S PEARL AVE
Mailing Address - Street 2:
Mailing Address - City:JOPLIN
Mailing Address - State:MO
Mailing Address - Zip Code:64801-2538
Mailing Address - Country:US
Mailing Address - Phone:417-781-6228
Mailing Address - Fax:417-781-6248
Practice Address - Street 1:315 S PEARL AVE
Practice Address - Street 2:
Practice Address - City:JOPLIN
Practice Address - State:MO
Practice Address - Zip Code:64801
Practice Address - Country:US
Practice Address - Phone:417-781-6228
Practice Address - Fax:417-781-6248
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-03
Last Update Date:2018-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2004008789101YP2500X
MO2005035596363LP2300X, 363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1003149261Medicaid
MO20048789Medicaid
KS244Medicaid