Provider Demographics
NPI:1972721702
Name:HARRIS, MARTHA LYNN (LPN)
Entity Type:Individual
Prefix:MS
First Name:MARTHA
Middle Name:LYNN
Last Name:HARRIS
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 1:339 TURNER DR
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:OH
Mailing Address - Zip Code:45036-1024
Mailing Address - Country:US
Mailing Address - Phone:513-932-7315
Mailing Address - Fax:
Practice Address - Street 1:526 HART ST
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45404-1935
Practice Address - Country:US
Practice Address - Phone:937-718-7382
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN-026651164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2477510Medicaid