Provider Demographics
NPI:1619657509
Name:MARTIN, LORI MICHELL
Entity Type:Individual
Prefix:PROF
First Name:LORI
Middle Name:MICHELL
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 1:4290 DEL PRADO CIR
Mailing Address - Street 2:
Mailing Address - City:PACE
Mailing Address - State:FL
Mailing Address - Zip Code:32571-3062
Mailing Address - Country:US
Mailing Address - Phone:850-619-6292
Mailing Address - Fax:
Practice Address - Street 1:4685 CHUMUCKLA HWY
Practice Address - Street 2:
Practice Address - City:PACE
Practice Address - State:FL
Practice Address - Zip Code:32571-1007
Practice Address - Country:US
Practice Address - Phone:850-736-8412
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-24
Last Update Date:2023-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL25893225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant