Provider Demographics
NPI:1356300024
Name:MARTIN, KATHLEEN (RN)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:
Last Name:MARTIN
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:211 NAUTILUS DR
Mailing Address - Street 2:APT. #4
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53705-4358
Mailing Address - Country:US
Mailing Address - Phone:608-233-5778
Mailing Address - Fax:
Practice Address - Street 1:211 NAUTILUS DR
Practice Address - Street 2:APT. #4
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53705-4358
Practice Address - Country:US
Practice Address - Phone:608-233-5778
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI54768-030163WH0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WH0200XNursing Service ProvidersRegistered NurseHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39834400Medicaid