Basic Information
| Provider Information | |||||||||
| NPI: | 1669675914 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LIBERTY | ||||||||
| FirstName: | MARTHA | ||||||||
| MiddleName: | KINGMAN | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | N.P. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5939 HARRY HINES BLVD | ||||||||
| Address2: | POB II SUITE 603 | ||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 753900001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2146455505 | ||||||||
| FaxNumber: | 2146455640 | ||||||||
| Practice Location | |||||||||
| Address1: | 5939 HARRY HINES BLVD | ||||||||
| Address2: | POB II SUITE 603 | ||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 753900001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2146455505 | ||||||||
| FaxNumber: | 2146455640 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/06/2007 | ||||||||
| LastUpdateDate: | 04/17/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2100X | 557107 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Acute Care |
No ID Information.