Provider Demographics
NPI:1851420657
Name:MARTIN, LUELLA PAULINE (LPN)
Entity Type:Individual
Prefix:MRS
First Name:LUELLA
Middle Name:PAULINE
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 1:17061 W HALIFAX LN
Mailing Address - Street 2:
Mailing Address - City:SURPRISE
Mailing Address - State:AZ
Mailing Address - Zip Code:85374-6887
Mailing Address - Country:US
Mailing Address - Phone:623-266-3028
Mailing Address - Fax:
Practice Address - Street 1:11800 W THOMPSON RANCH RD
Practice Address - Street 2:
Practice Address - City:EL MIRAGE
Practice Address - State:AZ
Practice Address - Zip Code:85335-3208
Practice Address - Country:US
Practice Address - Phone:623-523-8404
Practice Address - Fax:623-523-8411
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLP039599164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ897043Medicaid