Provider Demographics
NPI:1881998722
Name:ALLEN, MARTHA L
Entity type:Individual
Prefix:MRS
First Name:MARTHA
Middle Name:L
Last Name:ALLEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1860 46 STREET SOUTH
Mailing Address - Street 2:
Mailing Address - City:ST. PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33711
Mailing Address - Country:US
Mailing Address - Phone:727-565-3759
Mailing Address - Fax:
Practice Address - Street 1:1860 46 STREET SOUTH
Practice Address - Street 2:
Practice Address - City:ST. PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33711
Practice Address - Country:US
Practice Address - Phone:727-565-3759
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-07
Last Update Date:2011-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPN1270731310400000X, 347C00000X, 385H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
No347C00000XTransportation ServicesPrivate Vehicle
No385H00000XRespite Care FacilityRespite Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL691001796Medicaid