Healthcare Provider Details

I. General information

NPI: 1265539811
Provider Name (Legal Business Name): MS. MARY MARTHA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/17/2006
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4534 SE ELLSWORTH AVE
LAWTON OK
73501-8334
US

IV. Provider business mailing address

4534 SE ELLSWORTH AVE
LAWTON OK
73501-8334
US

V. Phone/Fax

Practice location:
  • Phone: 580-357-5880
  • Fax:
Mailing address:
  • Phone: 580-357-5880
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code376J00000X
TaxonomyHomemaker
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code385H00000X
TaxonomyRespite Care
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: