Provider Demographics
NPI:1396826681
Name:MARTIN, L ELLEN (CNM)
Entity Type:Individual
Prefix:
First Name:L
Middle Name:ELLEN
Last Name:MARTIN
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:LESLIE
Other - Middle Name:ELLEN
Other - Last Name:MARTIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:20 GLENLAKE PKWY
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30328
Mailing Address - Country:US
Mailing Address - Phone:770-677-6049
Mailing Address - Fax:770-677-7331
Practice Address - Street 1:20 GLENLAKE PKWY
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30328
Practice Address - Country:US
Practice Address - Phone:770-677-6049
Practice Address - Fax:770-677-7331
Is Sole Proprietor?:No
Enumeration Date:2006-10-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN041837207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
Q28540Medicare UPIN
42BBBRCMedicare ID - Type Unspecified