MEDICARE: MARTHA JOAN HUMPHREY 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	LPN0000015271	TN

General Provider Information

NPI Number	:	1881713386
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARTHA JOAN HUMPHREY LPN

Provider Business Mailing Address
First Line	:	17 HWY 152
Second Line	:	P O BOX 72
City	:	SPRING CREEK
State	:	TN
Zip	:	38378
Country	:	US
Telephone Number	:	731-695-4248
Fax Number	:

Provider Business Practice Location Address
First Line	:	804 N PARKWAY
Second Line	:
City	:	JACKSON
State	:	TN
Zip	:	38305-3058
Country	:	US
Telephone Number	:	731-423-3020
Fax Number	:

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

Provider Enumeration Date	:	03/28/2007
Last Update Date	:	07/08/2007

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