Provider Demographics
NPI:1740796473
Name:MARTIN, KIMBERLEY (STNA)
Entity Type:Individual
Prefix:MS
First Name:KIMBERLEY
Middle Name:
Last Name:MARTIN
Suffix:
Gender:F
Credentials:STNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:171 N WILSON RD APT 35
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43204-1222
Mailing Address - Country:US
Mailing Address - Phone:614-597-6083
Mailing Address - Fax:
Practice Address - Street 1:171 N WILSON RD APT 35
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43204-1222
Practice Address - Country:US
Practice Address - Phone:614-597-6083
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-18
Last Update Date:2017-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH400955920809251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2793571Medicaid