Provider Demographics
NPI:1437489366
Name:MARTIN, KELLY MARIE (CPM, LM)
Entity Type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:MARIE
Last Name:MARTIN
Suffix:
Gender:F
Credentials:CPM, LM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26674 MEADOW RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:ELKO
Mailing Address - State:MN
Mailing Address - Zip Code:55020-8535
Mailing Address - Country:US
Mailing Address - Phone:952-461-2302
Mailing Address - Fax:
Practice Address - Street 1:26674 MEADOW RIDGE DR
Practice Address - Street 2:
Practice Address - City:ELKO
Practice Address - State:MN
Practice Address - Zip Code:55020-8535
Practice Address - Country:US
Practice Address - Phone:952-461-2302
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-12-25
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNDOULA374J00000X
MN1092176B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes176B00000XOther Service ProvidersMidwife
No374J00000XNursing Service Related ProvidersDoula
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN374J00000XOtherTAXONOMY CODE 374J00000X