Provider Demographics
NPI:1760035851
Name:MARTIN, ADA B (LPN)
Entity Type:Individual
Prefix:
First Name:ADA
Middle Name:B
Last Name:MARTIN
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:206 AIRPORT CT STE B
Mailing Address - Street 2:
Mailing Address - City:MULLINS
Mailing Address - State:SC
Mailing Address - Zip Code:29574-6196
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1126 HIGHWAY 917 E
Practice Address - Street 2:
Practice Address - City:LATTA
Practice Address - State:SC
Practice Address - Zip Code:29565-4123
Practice Address - Country:US
Practice Address - Phone:843-319-4133
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-18
Last Update Date:2019-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC43882164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes164W00000XNursing Service ProvidersLicensed Practical NurseGroup - Multi-Specialty