Provider Demographics
NPI:1912441015
Name:MARTIN, KEIKILANI ADARA
Entity Type:Individual
Prefix:
First Name:KEIKILANI
Middle Name:ADARA
Last Name:MARTIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KEIKILANI
Other - Middle Name:ADARA
Other - Last Name:BENNETT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:305 FAIRVIEW AVE
Mailing Address - Street 2:
Mailing Address - City:HAMILTON
Mailing Address - State:OH
Mailing Address - Zip Code:45015-1411
Mailing Address - Country:US
Mailing Address - Phone:757-256-7147
Mailing Address - Fax:
Practice Address - Street 1:305 FAIRVIEW AVE
Practice Address - Street 2:
Practice Address - City:HAMILTON
Practice Address - State:OH
Practice Address - Zip Code:45015-1411
Practice Address - Country:US
Practice Address - Phone:757-256-7147
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-07
Last Update Date:2016-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH80525941310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility