Provider Demographics
NPI:1528136348
Name:HUBBARD, MARTHA DIANE (RN)
Entity type:Individual
Prefix:
First Name:MARTHA
Middle Name:DIANE
Last Name:HUBBARD
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1140 FOREST EDGE RD
Mailing Address - Street 2:
Mailing Address - City:WOODLAND PARK
Mailing Address - State:CO
Mailing Address - Zip Code:80863-1238
Mailing Address - Country:US
Mailing Address - Phone:719-687-3774
Mailing Address - Fax:
Practice Address - Street 1:11115 HWY 24
Practice Address - Street 2:UNIT 2 C
Practice Address - City:DIVIDE
Practice Address - State:CO
Practice Address - Zip Code:80814
Practice Address - Country:US
Practice Address - Phone:719-687-6416
Practice Address - Fax:719-687-6501
Is Sole Proprietor?:No
Enumeration Date:2006-12-01
Last Update Date:2011-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO94451163WC1500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC1500XNursing Service ProvidersRegistered NurseCommunity Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO07944515Medicaid