Provider Demographics
NPI:1972650653
Name:MARTIN, JUANETTA (LPN)
Entity Type:Individual
Prefix:MS
First Name:JUANETTA
Middle Name:
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:PO BOX 561
Mailing Address - Street 2:8057 WILLARD ROAD
Mailing Address - City:BASTROP
Mailing Address - State:LA
Mailing Address - Zip Code:71221-0561
Mailing Address - Country:US
Mailing Address - Phone:318-556-0043
Mailing Address - Fax:318-556-3633
Practice Address - Street 1:8057 WILLIARD RD
Practice Address - Street 2:
Practice Address - City:BASTROP
Practice Address - State:LA
Practice Address - Zip Code:71220-8939
Practice Address - Country:US
Practice Address - Phone:318-556-0043
Practice Address - Fax:318-556-3633
Is Sole Proprietor?:No
Enumeration Date:2007-01-04
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA900889164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1171506Medicaid
LA1564761Medicaid