Provider Demographics
NPI:1508322033
Name:MARTIN, LISA
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:MARTIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:582 HAWTHORNE HTS
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEBURG
Mailing Address - State:IN
Mailing Address - Zip Code:47025-7956
Mailing Address - Country:US
Mailing Address - Phone:513-304-4405
Mailing Address - Fax:
Practice Address - Street 1:582 HAWTHORNE HTS
Practice Address - Street 2:
Practice Address - City:LAWRENCEBURG
Practice Address - State:IN
Practice Address - Zip Code:47025-7956
Practice Address - Country:US
Practice Address - Phone:513-304-4405
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-20
Last Update Date:2019-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHLPN.154962.MEDS-IV164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse