Healthcare Provider Details

I. General information

NPI: 1023318953
Provider Name (Legal Business Name): HEATHER LEIGH MARTIN R.N.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/26/2010
Last Update Date: 10/26/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

317 MAIN STREET
EAGLE BUTTE SD
57625
US

IV. Provider business mailing address

PO BOX 1797
EAGLE BUTTE SD
57625-1797
US

V. Phone/Fax

Practice location:
  • Phone: 605-964-2814
  • Fax:
Mailing address:
  • Phone: 605-964-3004
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberR039505
License Number StateSD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: