Provider Demographics
NPI:1881787398
Name:MARTIN, WANDA JOY (MS)
Entity type:Individual
Prefix:
First Name:WANDA
Middle Name:JOY
Last Name:MARTIN
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1221 S BROADWAY
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40504-2701
Mailing Address - Country:US
Mailing Address - Phone:859-258-6200
Mailing Address - Fax:859-258-6203
Practice Address - Street 1:1221 S BROADWAY
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40504-2701
Practice Address - Country:US
Practice Address - Phone:859-258-4371
Practice Address - Fax:859-258-4326
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2022-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYKY-0104237600000X
KY100867231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
No237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid Fitter
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY70001045Medicaid
KY4000501OtherMEDICARE LAB GROUP
CB5773OtherRR MEDICARE GROUP
KY70001045Medicaid
KY37903705OtherMEDICAID LAB GROUP
CB5773OtherRR MEDICARE GROUP
KY70001045Medicaid