Provider Demographics
NPI:1154967099
Name:HABIYAMBERE, BUPE MARTHA M
Entity type:Individual
Prefix:
First Name:BUPE MARTHA
Middle Name:M
Last Name:HABIYAMBERE
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 1:124 JACKSON LOVE CIR
Mailing Address - Street 2:
Mailing Address - City:ERWIN
Mailing Address - State:TN
Mailing Address - Zip Code:37650-1920
Mailing Address - Country:US
Mailing Address - Phone:423-930-6593
Mailing Address - Fax:
Practice Address - Street 1:1057 12TH AVE
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:WA
Practice Address - Zip Code:98632-2509
Practice Address - Country:US
Practice Address - Phone:360-636-3892
Practice Address - Fax:360-636-3892
Is Sole Proprietor?:No
Enumeration Date:2019-11-26
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP61041972363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health