Provider Demographics
NPI:1144602640
Name:MARTIN, TRACI LYNN (NP)
Entity Type:Individual
Prefix:
First Name:TRACI
Middle Name:LYNN
Last Name:MARTIN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:TRACI
Other - Middle Name:LYNN
Other - Last Name:LYLE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 781076
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48278-1076
Mailing Address - Country:US
Mailing Address - Phone:317-528-4800
Mailing Address - Fax:317-865-1479
Practice Address - Street 1:10701 ALLIANCE DR STE A
Practice Address - Street 2:
Practice Address - City:CAMBY
Practice Address - State:IN
Practice Address - Zip Code:46113-8837
Practice Address - Country:US
Practice Address - Phone:317-856-7083
Practice Address - Fax:317-856-7332
Is Sole Proprietor?:No
Enumeration Date:2015-06-22
Last Update Date:2023-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71005608A363L00000X, 363LF0000X
IN28189657A363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN71005608AOtherAPN LICENSE