Provider Demographics
NPI:1891954236
Name:MARTIN, MARLANE K (LPN)
Entity Type:Individual
Prefix:
First Name:MARLANE
Middle Name:K
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 1:3846 BRUMBAUGH BLVD
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45416-1506
Mailing Address - Country:US
Mailing Address - Phone:937-270-3791
Mailing Address - Fax:
Practice Address - Street 1:3846 BRUMBAUGH BLVD
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45416-1506
Practice Address - Country:US
Practice Address - Phone:937-270-3791
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-02
Last Update Date:2013-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH154570-M-IV164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2772932Medicaid