Basic Information
| Provider Information | |||||||||
| NPI: | 1285606970 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MARTIN | ||||||||
| FirstName: | LUCY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3401 N PERRYVILLE RD | ||||||||
| Address2: | |||||||||
| City: | ROCKFORD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 611148011 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8159712000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3401 N PERRYVILLE RD | ||||||||
| Address2: | |||||||||
| City: | ROCKFORD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 611148011 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8159712000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/06/2006 | ||||||||
| LastUpdateDate: | 11/24/2009 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 041269108 | IL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | L90720 | 01 | IL | MEDICARE PRIOR 7/15/2007 | OTHER |