Provider Demographics
NPI:1912446089
Name:MARTIN, NICOLE DUSHAUN (LPN)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:DUSHAUN
Last Name:MARTIN
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2641 N MORELAND BLVD
Mailing Address - Street 2:APT 4
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44120-1489
Mailing Address - Country:US
Mailing Address - Phone:216-774-9027
Mailing Address - Fax:
Practice Address - Street 1:2641 N MORELAND BLVD
Practice Address - Street 2:APT 4
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44120-1489
Practice Address - Country:US
Practice Address - Phone:216-774-9027
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-22
Last Update Date:2017-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH161598164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse