Provider Demographics
NPI:1982654653
Name:MARTIN, ELISSA E (CNP)
Entity Type:Individual
Prefix:
First Name:ELISSA
Middle Name:E
Last Name:MARTIN
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:915 WEST MICHIGAN ST
Mailing Address - Street 2:
Mailing Address - City:SIDNEY
Mailing Address - State:OH
Mailing Address - Zip Code:45365-2401
Mailing Address - Country:US
Mailing Address - Phone:937-394-2900
Mailing Address - Fax:937-394-3602
Practice Address - Street 1:104 DIAMOND DRIVE
Practice Address - Street 2:
Practice Address - City:ANNA
Practice Address - State:OH
Practice Address - Zip Code:45302
Practice Address - Country:US
Practice Address - Phone:937-394-2900
Practice Address - Fax:937-394-3602
Is Sole Proprietor?:No
Enumeration Date:2006-05-11
Last Update Date:2009-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCOA-08452-NP363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2622782Medicaid
OHNP19441Medicare PIN
OH2622782Medicaid