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General NPI Number Information
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NPI Number | 1174982045
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Entity Type | Individual
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Provider Name | MARTI JO SIDWELL
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Gender | Female
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Dates
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Enumeration Date | 02/19/2016
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Last Update Date | 09/03/2020
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Provider Practice Location Address
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Address Line | 400 N 100 E SUITE 205
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City | GREEN RIVER
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State | WY
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Zip | 82935
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Country | US
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Telephone | 307-362-2424
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Fax | 307-222-0614
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Provider Business Mailing Address
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Address Line | 688 ANTELOPE DR LOT 21
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City | ROCK SPRINGS
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State | WY
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Zip | 82901-3016
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Country | US
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Telephone | 307-274-7500
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251B00000X
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Taxonomy Name | Case Management Agency
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License Number |
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License Number State |
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