Provider Demographics
NPI:1881231355
Name:MARTIN, STEPHANIE (RN)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:MARTIN
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4241 HWY 14 W
Mailing Address - Street 2:
Mailing Address - City:CHRISTOPHER
Mailing Address - State:IL
Mailing Address - Zip Code:62822-1037
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:103 COMMERCE ST
Practice Address - Street 2:
Practice Address - City:CARMI
Practice Address - State:IL
Practice Address - Zip Code:62821-2223
Practice Address - Country:US
Practice Address - Phone:618-384-5686
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-04
Last Update Date:2019-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041422960163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse