Provider Demographics
NPI:1144622929
Name:MARTIN, MARY ANN
Entity Type:Individual
Prefix:
First Name:MARY ANN
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 1:2458 S WALNUT ST
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47401-7730
Mailing Address - Country:US
Mailing Address - Phone:812-337-8121
Mailing Address - Fax:
Practice Address - Street 1:2458 S WALNUT ST
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47401-7730
Practice Address - Country:US
Practice Address - Phone:812-337-8121
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-09-23
Last Update Date:2014-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174N00000XOther Service ProvidersLactation Consultant, Non-RN
Provider Identifiers
StateIdentifier IDID TypeIssuer
11121956OtherINTERNATIONAL BOARD OF LACTATION CONSULTANT EXAMINERS