Provider Demographics
NPI:1285792598
Name:BRECKENRIDGE, MARTHA ANN (NP)
Entity type:Individual
Prefix:
First Name:MARTHA
Middle Name:ANN
Last Name:BRECKENRIDGE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 346
Mailing Address - Street 2:
Mailing Address - City:DESOTO
Mailing Address - State:TX
Mailing Address - Zip Code:75123-0346
Mailing Address - Country:US
Mailing Address - Phone:214-724-3723
Mailing Address - Fax:972-709-4600
Practice Address - Street 1:423 W WHEATLAND RD STE 103
Practice Address - Street 2:
Practice Address - City:DUNCANVILLE
Practice Address - State:TX
Practice Address - Zip Code:75116-4630
Practice Address - Country:US
Practice Address - Phone:469-567-1234
Practice Address - Fax:972-709-4600
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-06
Last Update Date:2023-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251E00000X
TX242859363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
No251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX188180701Medicaid
TX00X578Medicare UPIN