Provider Demographics
NPI:1508313859
Name:RICHARDSON, MARTINA (LPN)
Entity Type:Individual
Prefix:MS
First Name:MARTINA
Middle Name:
Last Name:RICHARDSON
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:55 GRANT ST
Mailing Address - Street 2:106B
Mailing Address - City:PAINESVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:44077-2538
Mailing Address - Country:US
Mailing Address - Phone:440-622-8511
Mailing Address - Fax:
Practice Address - Street 1:55 GRANT ST
Practice Address - Street 2:106B
Practice Address - City:PAINESVILLE
Practice Address - State:OH
Practice Address - Zip Code:44077-2538
Practice Address - Country:US
Practice Address - Phone:440-622-8511
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-03
Last Update Date:2016-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN.162086-M-IV164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse