Basic Information
| Provider Information | |||||||||
| NPI: | 1447304696 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MARTIN | ||||||||
| FirstName: | AMY | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | SLP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 707 ELDRIDGE AVE E | ||||||||
| Address2: | |||||||||
| City: | WYNNE | ||||||||
| State: | AR | ||||||||
| PostalCode: | 723964032 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8702088989 | ||||||||
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| Practice Location | |||||||||
| Address1: | 707 ELDRIDGE AVE E | ||||||||
| Address2: | |||||||||
| City: | WYNNE | ||||||||
| State: | AR | ||||||||
| PostalCode: | 723964032 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8702088989 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/23/2007 | ||||||||
| LastUpdateDate: | 07/09/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | SP 2407 | AR | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
ID Information
| ID | Type | State | Issuer | Description | 12091072 | 01 | AR | ASHA ACCOUNT NUMBER | OTHER | 161714721 | 05 | AR | MEDICAID | 5A099 | 01 | AR | BLUE CROSS & BLUE SHIELD | OTHER |