Provider Demographics
NPI:1053452839
Name:WARDEN, MARTI LEA (APN)
Entity type:Individual
Prefix:MRS
First Name:MARTI
Middle Name:LEA
Last Name:WARDEN
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1359
Mailing Address - Street 2:
Mailing Address - City:AVA
Mailing Address - State:MO
Mailing Address - Zip Code:65608-1359
Mailing Address - Country:US
Mailing Address - Phone:417-683-4831
Mailing Address - Fax:417-683-1602
Practice Address - Street 1:201 S. ELM STREET
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:MO
Practice Address - Zip Code:65655-0000
Practice Address - Country:US
Practice Address - Phone:417-679-2775
Practice Address - Fax:417-683-1602
Is Sole Proprietor?:No
Enumeration Date:2007-02-12
Last Update Date:2014-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO138415363L00000X
ARA01688363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR53356OtherARKANSAS BCBS