Provider Demographics
NPI:1922694538
Name:MARTIN, FELICIA
Entity Type:Individual
Prefix:
First Name:FELICIA
Middle Name:
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 1:1230 SUMMIT ST
Mailing Address - Street 2:
Mailing Address - City:PORTSMOUTH
Mailing Address - State:OH
Mailing Address - Zip Code:45662-3718
Mailing Address - Country:US
Mailing Address - Phone:740-353-2294
Mailing Address - Fax:
Practice Address - Street 1:1230 SUMMIT ST
Practice Address - Street 2:
Practice Address - City:PORTSMOUTH
Practice Address - State:OH
Practice Address - Zip Code:45662-3718
Practice Address - Country:US
Practice Address - Phone:740-353-2294
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-17
Last Update Date:2020-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2277665Medicaid