Provider Demographics
NPI:1114465325
Name:MARTIN, STEPHANIE (CNP)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:MARTIN
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10058 COOLEY RD
Mailing Address - Street 2:STE 6
Mailing Address - City:BROOKVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47012-9509
Mailing Address - Country:US
Mailing Address - Phone:765-647-0808
Mailing Address - Fax:795-647-2728
Practice Address - Street 1:10058 COOLEY RD
Practice Address - Street 2:STE C
Practice Address - City:BROOKVILLE
Practice Address - State:IN
Practice Address - Zip Code:47012-9509
Practice Address - Country:US
Practice Address - Phone:765-647-0808
Practice Address - Fax:795-647-2728
Is Sole Proprietor?:No
Enumeration Date:2017-02-08
Last Update Date:2017-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH020392363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily