Provider Demographics
NPI:1598804973
Name:MARTIN, CAROL ENNIS (APRN)
Entity Type:Individual
Prefix:
First Name:CAROL
Middle Name:ENNIS
Last Name:MARTIN
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:740 S. LIMESTONE
Mailing Address - Street 2:THE KENTUCKY CLINIC WING D - J252
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40536-0284
Mailing Address - Country:US
Mailing Address - Phone:859-218-0362
Mailing Address - Fax:859-257-5013
Practice Address - Street 1:THE KENTUCKY CLINIC WING D J252
Practice Address - Street 2:740 S. LIMESTONE
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40536
Practice Address - Country:US
Practice Address - Phone:859-323-2089
Practice Address - Fax:859-218-7487
Is Sole Proprietor?:No
Enumeration Date:2007-02-05
Last Update Date:2018-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3002688363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY78026887Medicaid