Provider Demographics
NPI:1366507428
Name:MARTIN, SANDRA KAY (LPN)
Entity Type:Individual
Prefix:MRS
First Name:SANDRA
Middle Name:KAY
Last Name:MARTIN
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:MRS
Other - First Name:SANDRA
Other - Middle Name:KAY
Other - Last Name:SLABAUGH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPN
Mailing Address - Street 1:3211 UNIT D WOODLAND TRAIL
Mailing Address - Street 2:
Mailing Address - City:CORTLAND
Mailing Address - State:OH
Mailing Address - Zip Code:44410
Mailing Address - Country:US
Mailing Address - Phone:330-469-5626
Mailing Address - Fax:
Practice Address - Street 1:3211 UNIT D WOODLAND TRAIL
Practice Address - Street 2:
Practice Address - City:CORTLAND
Practice Address - State:OH
Practice Address - Zip Code:44410
Practice Address - Country:US
Practice Address - Phone:330-469-5626
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-27
Last Update Date:2012-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN084466164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2088226Medicaid