Provider Demographics
NPI:1598491359
Name:MARTIN, MALLORY WINNIE-MAE (CPM, LM)
Entity type:Individual
Prefix:
First Name:MALLORY
Middle Name:WINNIE-MAE
Last Name:MARTIN
Suffix:
Gender:F
Credentials:CPM, LM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10345 ALTA VISTA RD
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76244-6501
Mailing Address - Country:US
Mailing Address - Phone:817-562-2828
Mailing Address - Fax:
Practice Address - Street 1:10345 ALTA VISTA RD
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76244-6501
Practice Address - Country:US
Practice Address - Phone:817-562-2828
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-25
Last Update Date:2022-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX99491176B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes176B00000XOther Service ProvidersMidwife