Provider Demographics
NPI:1396441127
Name:THELUSMA, MARTINE
Entity type:Individual
Prefix:
First Name:MARTINE
Middle Name:
Last Name:THELUSMA
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 1:978 GRAY DR
Mailing Address - Street 2:
Mailing Address - City:PICKERINGTON
Mailing Address - State:OH
Mailing Address - Zip Code:43147-9358
Mailing Address - Country:US
Mailing Address - Phone:954-655-6275
Mailing Address - Fax:
Practice Address - Street 1:978 GRAY DR
Practice Address - Street 2:
Practice Address - City:PICKERINGTON
Practice Address - State:OH
Practice Address - Zip Code:43147-9358
Practice Address - Country:US
Practice Address - Phone:954-655-6275
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-02
Last Update Date:2023-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHVK695545172A00000X
172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver