Provider Demographics
NPI:1417167297
Name:MARTIN, KATHRYN ANN (LVN)
Entity Type:Individual
Prefix:
First Name:KATHRYN
Middle Name:ANN
Last Name:MARTIN
Suffix:
Gender:F
Credentials:LVN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 MISSION RANCH BLVD APT 158
Mailing Address - Street 2:
Mailing Address - City:CHICO
Mailing Address - State:CA
Mailing Address - Zip Code:95926-5136
Mailing Address - Country:US
Mailing Address - Phone:530-680-3270
Mailing Address - Fax:
Practice Address - Street 1:400 MISSION RANCH BLVD APT 158
Practice Address - Street 2:
Practice Address - City:CHICO
Practice Address - State:CA
Practice Address - Zip Code:95926-5136
Practice Address - Country:US
Practice Address - Phone:530-680-3270
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAVN139591164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
CARVN004970Medicaid
CAEPS016840Medicaid