Healthcare Provider Details

I. General information

NPI: 1992839641
Provider Name (Legal Business Name): MARTHA L COVENTRY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/15/2007
Last Update Date: 12/15/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10539 APPLEWOOD ROAD
SISTER BAY WI
54234
US

IV. Provider business mailing address

PO BOX 104
ELLISON BAY WI
54210-0104
US

V. Phone/Fax

Practice location:
  • Phone: 920-854-4154
  • Fax:
Mailing address:
  • Phone: 920-493-5356
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number3069
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: