Provider Demographics
NPI:1619460862
Name:MARTIN, SHELLIE LEIGH (COMMUNITY HEALTH WOR)
Entity Type:Individual
Prefix:
First Name:SHELLIE
Middle Name:LEIGH
Last Name:MARTIN
Suffix:
Gender:F
Credentials:COMMUNITY HEALTH WOR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 149
Mailing Address - Street 2:
Mailing Address - City:OUZINKIE
Mailing Address - State:AK
Mailing Address - Zip Code:99644-0149
Mailing Address - Country:US
Mailing Address - Phone:907-486-1389
Mailing Address - Fax:907-680-2292
Practice Address - Street 1:500 MAIN STREET
Practice Address - Street 2:
Practice Address - City:OUZINKIE
Practice Address - State:AK
Practice Address - Zip Code:99644
Practice Address - Country:US
Practice Address - Phone:907-486-1389
Practice Address - Fax:907-680-2292
Is Sole Proprietor?:No
Enumeration Date:2018-06-12
Last Update Date:2018-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker