Provider Demographics
NPI:1467757880
Name:MARTIN, CONNIE ANN (REGISTERED NURSE)
Entity Type:Individual
Prefix:MRS
First Name:CONNIE
Middle Name:ANN
Last Name:MARTIN
Suffix:
Gender:F
Credentials:REGISTERED NURSE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1044 BROOKDALE DR
Mailing Address - Street 2:
Mailing Address - City:CRESTLINE
Mailing Address - State:OH
Mailing Address - Zip Code:44827-9678
Mailing Address - Country:US
Mailing Address - Phone:567-303-5614
Mailing Address - Fax:419-405-4047
Practice Address - Street 1:1044 BROOKDALE DR
Practice Address - Street 2:
Practice Address - City:CRESTLINE
Practice Address - State:OH
Practice Address - Zip Code:44827-9678
Practice Address - Country:US
Practice Address - Phone:567-303-5614
Practice Address - Fax:419-405-4047
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-14
Last Update Date:2011-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRN222893163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse