Provider Demographics
NPI:1003499880
Name:MARTIN, LORI ANN (CNM)
Entity type:Individual
Prefix:
First Name:LORI
Middle Name:ANN
Last Name:MARTIN
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:64444A STATE ROAD 19
Mailing Address - Street 2:
Mailing Address - City:GOSHEN
Mailing Address - State:IN
Mailing Address - Zip Code:46526-9421
Mailing Address - Country:US
Mailing Address - Phone:574-849-4646
Mailing Address - Fax:
Practice Address - Street 1:1929 W LINCOLN AVE
Practice Address - Street 2:
Practice Address - City:GOSHEN
Practice Address - State:IN
Practice Address - Zip Code:46526-5909
Practice Address - Country:US
Practice Address - Phone:574-849-4646
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-30
Last Update Date:2021-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN09000372A176B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes176B00000XOther Service ProvidersMidwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN09000372AOtherNURSE MIDWIFE LICENSE NUMBER