Provider Demographics
NPI:1770928749
Name:MARTNICK, JENNIFER ANN (APRN, NPC, MSN)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:ANN
Last Name:MARTNICK
Suffix:
Gender:F
Credentials:APRN, NPC, MSN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17876 SAINT CLAIR AVE
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44110-2602
Mailing Address - Country:US
Mailing Address - Phone:216-486-6512
Mailing Address - Fax:
Practice Address - Street 1:17876 SAINT CLAIR AVE
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44110-2602
Practice Address - Country:US
Practice Address - Phone:216-486-6512
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-06
Last Update Date:2013-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCOA14445, RN 296632363LA2200X
OHCOA14445, RN296632363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHCOA14445OtherRN, COA, AANP
OHAG0313017OtherAANP
OHRN296632OtherRN