Provider Demographics
NPI:1033329701
Name:MARTIN, LEAH MARANDA (ANP)
Entity Type:Individual
Prefix:MRS
First Name:LEAH
Middle Name:MARANDA
Last Name:MARTIN
Suffix:
Gender:F
Credentials:ANP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:275 CHERRY LN
Mailing Address - Street 2:
Mailing Address - City:RUSSELLVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72802-2117
Mailing Address - Country:US
Mailing Address - Phone:479-284-3029
Mailing Address - Fax:479-284-2244
Practice Address - Street 1:1014 HARKRIDER ST
Practice Address - Street 2:SUITE B
Practice Address - City:CONWAY
Practice Address - State:AR
Practice Address - Zip Code:72032-4404
Practice Address - Country:US
Practice Address - Phone:501-327-7100
Practice Address - Fax:501-279-9011
Is Sole Proprietor?:No
Enumeration Date:2007-05-23
Last Update Date:2007-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARA01850363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily