Provider Demographics
NPI:1235119819
Name:MARTIN, MARY A (CNM)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:A
Last Name:MARTIN
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12880 MANNING LAKE RD
Mailing Address - Street 2:
Mailing Address - City:DELTON
Mailing Address - State:MI
Mailing Address - Zip Code:49046-9659
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:12880 MANNING LAKE RD
Practice Address - Street 2:
Practice Address - City:DELTON
Practice Address - State:MI
Practice Address - Zip Code:49046-9659
Practice Address - Country:US
Practice Address - Phone:269-999-9999
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-19
Last Update Date:2024-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704165662367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2951920Medicaid
MI2951920Medicaid
MIM97850016Medicare PIN
MIM74680003Medicare PIN
S69907Medicare UPIN