Provider Demographics
NPI:1871259606
Name:MIMS, MARTENIA (LPN BSHCM MSHS)
Entity type:Individual
Prefix:
First Name:MARTENIA
Middle Name:
Last Name:MIMS
Suffix:
Gender:F
Credentials:LPN BSHCM MSHS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:619 BENHAM ST
Mailing Address - Street 2:
Mailing Address - City:HAMDEN
Mailing Address - State:CT
Mailing Address - Zip Code:06514-2656
Mailing Address - Country:US
Mailing Address - Phone:475-655-4159
Mailing Address - Fax:
Practice Address - Street 1:619 BENHAM ST
Practice Address - Street 2:
Practice Address - City:HAMDEN
Practice Address - State:CT
Practice Address - Zip Code:06514-2656
Practice Address - Country:US
Practice Address - Phone:475-655-4159
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-16
Last Update Date:2021-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA204554164X00000X
RILPN09927164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes164W00000XNursing Service ProvidersLicensed Practical NurseGroup - Multi-Specialty
No164X00000XNursing Service ProvidersLicensed Vocational Nurse