Provider Demographics
NPI:1407182926
Name:MARTIN, RENATTIE LENORA (NP-C)
Entity Type:Individual
Prefix:MS
First Name:RENATTIE
Middle Name:LENORA
Last Name:MARTIN
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11000 OPTUM CIR
Mailing Address - Street 2:
Mailing Address - City:EDEN PRAIRIE
Mailing Address - State:MN
Mailing Address - Zip Code:55344-2503
Mailing Address - Country:US
Mailing Address - Phone:855-247-8374
Mailing Address - Fax:
Practice Address - Street 1:16616 BILTMORE AVE
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44128-1442
Practice Address - Country:US
Practice Address - Phone:216-798-7433
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-10-19
Last Update Date:2019-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCOA.10896363L00000X
CA95001616363L00000X
OHCOA10896363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH3013349Medicaid
CAP01817207-DU4034OtherRAILROAD MEDICARE
CAP01817209-DU5182OtherRAILROAD MEDICARE
CAP01817207-DU4034OtherRAILROAD MEDICARE
CACA241803-GA222AMedicare PIN