Provider Demographics
NPI:1073224630
Name:MARTIN, MACOLE JOI (APRN)
Entity type:Individual
Prefix:
First Name:MACOLE
Middle Name:JOI
Last Name:MARTIN
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:304 N JEFFERSON AVE
Mailing Address - Street 2:
Mailing Address - City:IOLA
Mailing Address - State:KS
Mailing Address - Zip Code:66749-2327
Mailing Address - Country:US
Mailing Address - Phone:816-810-5957
Mailing Address - Fax:
Practice Address - Street 1:10630 WENZEL AVE
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64137-1858
Practice Address - Country:US
Practice Address - Phone:816-810-5957
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-12-05
Last Update Date:2023-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS53-81875-062363LP0808X, 363LP0808X
KS14-130657-062163WP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health