Provider Demographics
NPI:1184123127
Name:SHIRLEY, MARTINA ELAINE (BA)
Entity type:Individual
Prefix:
First Name:MARTINA
Middle Name:ELAINE
Last Name:SHIRLEY
Suffix:
Gender:F
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:926 KINSER AVE
Mailing Address - Street 2:
Mailing Address - City:SHELBYVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40065-1367
Mailing Address - Country:US
Mailing Address - Phone:502-509-4590
Mailing Address - Fax:
Practice Address - Street 1:2210 GOLDSMITH LN STE 221B
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40218-1082
Practice Address - Country:US
Practice Address - Phone:502-509-4590
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-05
Last Update Date:2018-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator