Basic Information
| Provider Information | |||||||||
| NPI: | 1033662457 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MARTIN | ||||||||
| FirstName: | ANN | ||||||||
| MiddleName: | RACHELLE | ||||||||
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| Credential: | RN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2065 STONERIDGE DR | ||||||||
| Address2: | |||||||||
| City: | CIRCLEVILLE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 431138956 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7405001391 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2065 STONERIDGE DR | ||||||||
| Address2: | |||||||||
| City: | CIRCLEVILLE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 431138956 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7405001391 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/02/2016 | ||||||||
| LastUpdateDate: | 05/24/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/24/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 164W00000X | LPN.158486.MEDS-IV | OH | N | Nursing Service Providers | Licensed Practical Nurse | 163WA0400X | RN.483674 | OH | Y | Nursing Service Providers | Registered Nurse | Addiction (Substance Use Disorder) |
No ID Information.