Provider Demographics
NPI:1225645104
Name:MARTIN, KIM
Entity Type:Individual
Prefix:
First Name:KIM
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 1:161 CIRCLEVILLE AVE
Mailing Address - Street 2:
Mailing Address - City:ASHVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43103-1545
Mailing Address - Country:US
Mailing Address - Phone:740-601-4325
Mailing Address - Fax:
Practice Address - Street 1:161 CIRCLEVILLE AVE
Practice Address - Street 2:
Practice Address - City:ASHVILLE
Practice Address - State:OH
Practice Address - Zip Code:43103-1545
Practice Address - Country:US
Practice Address - Phone:740-601-4325
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-25
Last Update Date:2020-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH376J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376J00000XNursing Service Related ProvidersHomemaker
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH6508274Medicaid