Provider Demographics
NPI:1043783434
Name:MARTIN, IVORIE
Entity Type:Individual
Prefix:
First Name:IVORIE
Middle Name:
Last Name:MARTIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5658 YORKTOWN LN
Mailing Address - Street 2:
Mailing Address - City:AUSTINTOWN
Mailing Address - State:OH
Mailing Address - Zip Code:44515-1922
Mailing Address - Country:US
Mailing Address - Phone:330-397-9078
Mailing Address - Fax:
Practice Address - Street 1:5658 YORKTOWN LN
Practice Address - Street 2:
Practice Address - City:AUSTINTOWN
Practice Address - State:OH
Practice Address - Zip Code:44515-1922
Practice Address - Country:US
Practice Address - Phone:330-397-9078
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-08
Last Update Date:2019-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHLPN.110385.MEDS164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes164W00000XNursing Service ProvidersLicensed Practical NurseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHLPN.110385.MEDSMedicaid