Provider Demographics
NPI:1740616192
Name:MARTIN, ALYSE C (APRN)
Entity Type:Individual
Prefix:
First Name:ALYSE
Middle Name:C
Last Name:MARTIN
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:ALYSE
Other - Middle Name:C
Other - Last Name:HARRIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:APRN
Mailing Address - Street 1:100 E LIBERTY ST SUITE 800
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40202-1428
Mailing Address - Country:US
Mailing Address - Phone:502-261-0655
Mailing Address - Fax:502-261-0699
Practice Address - Street 1:9569 TAYLORSVILLE ROAD SUITE 109
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40299
Practice Address - Country:US
Practice Address - Phone:502-261-0655
Practice Address - Fax:502-261-0699
Is Sole Proprietor?:No
Enumeration Date:2013-09-17
Last Update Date:2020-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3008308363LF0000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100261240Medicaid
KY7100261240Medicaid