Provider Demographics
NPI:1558776054
Name:MARTIN, BRIANNA (CNA)
Entity Type:Individual
Prefix:
First Name:BRIANNA
Middle Name:
Last Name:MARTIN
Suffix:
Gender:F
Credentials:CNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:813 S BEECH ST
Mailing Address - Street 2:
Mailing Address - City:PICAYUNE
Mailing Address - State:MS
Mailing Address - Zip Code:39466-5017
Mailing Address - Country:US
Mailing Address - Phone:601-569-3924
Mailing Address - Fax:
Practice Address - Street 1:813 S BEECH ST
Practice Address - Street 2:
Practice Address - City:PICAYUNE
Practice Address - State:MS
Practice Address - Zip Code:39466-5017
Practice Address - Country:US
Practice Address - Phone:601-569-3924
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-24
Last Update Date:2014-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes385H00000XRespite Care FacilityRespite Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
00000000000OtherPENDING MEDICAID