Provider Demographics
NPI:1407884703
Name:MARTZ, JACQUELINE RAE (RN, CNS)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:RAE
Last Name:MARTZ
Suffix:
Gender:F
Credentials:RN, CNS
Other - Prefix:
Other - First Name:JACQUELINE
Other - Middle Name:RAE
Other - Last Name:MOORE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN, CNS
Mailing Address - Street 1:441 E 8TH ST
Mailing Address - Street 2:
Mailing Address - City:LIMA
Mailing Address - State:OH
Mailing Address - Zip Code:45804-2482
Mailing Address - Country:US
Mailing Address - Phone:419-221-3072
Mailing Address - Fax:419-222-3927
Practice Address - Street 1:441 E 8TH ST
Practice Address - Street 2:
Practice Address - City:LIMA
Practice Address - State:OH
Practice Address - Zip Code:45804-2482
Practice Address - Country:US
Practice Address - Phone:419-221-3072
Practice Address - Fax:419-222-3927
Is Sole Proprietor?:No
Enumeration Date:2006-06-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHNS07725364SA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SA2200XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2554827Medicaid
OHMA2026271Medicare ID - Type Unspecified
OH2554827Medicaid