Provider Demographics
NPI:1194124354
Name:GACEK, MARTHA
Entity type:Individual
Prefix:
First Name:MARTHA
Middle Name:
Last Name:GACEK
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 1:1843 US ROUTE 50
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:45118-9661
Mailing Address - Country:US
Mailing Address - Phone:513-315-8971
Mailing Address - Fax:
Practice Address - Street 1:2040 US ROUTE 50
Practice Address - Street 2:
Practice Address - City:BATAVIA
Practice Address - State:OH
Practice Address - Zip Code:45103-8694
Practice Address - Country:US
Practice Address - Phone:513-732-7017
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-13
Last Update Date:2014-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRN233253163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse