Provider Demographics
NPI:1770183899
Name:MARTIN, ANGELA LAKERSHA
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:LAKERSHA
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 1:2810 CYCLORAMA DR
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45211-8330
Mailing Address - Country:US
Mailing Address - Phone:513-260-0975
Mailing Address - Fax:
Practice Address - Street 1:2810 CYCLORAMA DR
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45211-8330
Practice Address - Country:US
Practice Address - Phone:513-260-0975
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-28
Last Update Date:2020-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH3116256171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor