Healthcare Provider Details

I. General information

NPI: 1407100290
Provider Name (Legal Business Name): ANN MARTIN MHRS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/01/2012
Last Update Date: 11/01/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9860 MIDDLE CREEK RD
UPPER LAKE CA
95485-9265
US

IV. Provider business mailing address

PO BOX 501
KELSEYVILLE CA
95451-0501
US

V. Phone/Fax

Practice location:
  • Phone: 707-472-2922
  • Fax:
Mailing address:
  • Phone: 707-472-2922
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: