Provider Demographics
NPI:1023625159
Name:MARTIN, AMIE LORAINE
Entity type:Individual
Prefix:
First Name:AMIE
Middle Name:LORAINE
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 1:1101 I AVE
Mailing Address - Street 2:
Mailing Address - City:LA GRANDE
Mailing Address - State:OR
Mailing Address - Zip Code:97850-2043
Mailing Address - Country:US
Mailing Address - Phone:541-962-0162
Mailing Address - Fax:
Practice Address - Street 1:200 SE HAILEY AVE STE 204
Practice Address - Street 2:
Practice Address - City:PENDLETON
Practice Address - State:OR
Practice Address - Zip Code:97801-3072
Practice Address - Country:US
Practice Address - Phone:541-962-0162
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-23
Last Update Date:2020-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR20-CRM-227175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist