Provider Demographics
NPI:1669570552
Name:MARTIN, ANGELIQUE M (LD)
Entity type:Individual
Prefix:
First Name:ANGELIQUE
Middle Name:M
Last Name:MARTIN
Suffix:
Gender:F
Credentials:LD
Other - Prefix:
Other - First Name:ANGELIQUE
Other - Middle Name:
Other - Last Name:NAGEL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LD
Mailing Address - Street 1:4140 W MEMORIAL RD STE 321
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73120-8300
Mailing Address - Country:US
Mailing Address - Phone:405-748-4726
Mailing Address - Fax:405-607-8497
Practice Address - Street 1:4140 W MEMORIAL RD STE 321
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73120
Practice Address - Country:US
Practice Address - Phone:405-748-4726
Practice Address - Fax:405-607-8497
Is Sole Proprietor?:No
Enumeration Date:2006-09-21
Last Update Date:2020-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR1796133V00000X
OK970133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100166870AMedicaid
OK970OtherLD LICENSE