Individual
MARTAVIA STANFORD
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
LABORATORY DIRECTOR
Contact information
Practice address
120 BISHOPS WAY STE 165, BROOKFIELD, WI 53005-6249
(414) 355-5525
(414) 240-4595
Mailing address
120 BISHOPS WAY STE 165, BROOKFIELD, WI 53005-6249
(414) 355-5525
(414) 240-4595
Taxonomy
Speciality
Code
Description
License number
State
101YP1600X
Pastoral Counselor
—
—
247ZC0005X
Clinical Laboratory Director (Non-physician)
Primary
52D2261520
WI
372600000X
Adult Companion
—
—
374U00000X
Home Health Aide
—
—
376J00000X
Homemaker
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
52D2261520
CLIA STATE OF WISCONSIN
WI
Enumeration date
10/07/2022
Last updated
10/07/2022
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