MEDICARE: MELVIA SUE ANN MARTIN LPN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	164W00000X	Licensed Practical Nurse	56727	OK

General Provider Information

NPI Number	:	1619567799
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MELVIA SUE ANN MARTIN LPN

Provider Business Mailing Address
First Line	:	6014 NW 16TH ST
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73127-2604
Country	:	US
Telephone Number	:	405-706-3362
Fax Number	:

Provider Business Practice Location Address
First Line	:	6014 NW 16TH ST
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73127-2604
Country	:	US
Telephone Number	:	405-706-3362
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/22/2021
Last Update Date	:	01/22/2021

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