Basic Information
| Provider Information | |||||||||
| NPI: | 1871236711 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MARTIN | ||||||||
| FirstName: | COURTNEY | ||||||||
| MiddleName: | JO ANNE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | RN | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | RODE | ||||||||
| OtherFirstName: | COURTNEY | ||||||||
| OtherMiddleName: | JO ANNE | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 4325 SECOR ROAD | ||||||||
| Address2: | BUILDING 3, FLOOR 2 | ||||||||
| City: | TOLEDO | ||||||||
| State: | OH | ||||||||
| PostalCode: | 43623 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4194795485 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 4235 SECOR RD BLDG 32ND | ||||||||
| Address2: | |||||||||
| City: | TOLEDO | ||||||||
| State: | OH | ||||||||
| PostalCode: | 436234299 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4194795480 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/19/2022 | ||||||||
| LastUpdateDate: | 08/10/2022 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 08/04/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | APRN.CNP.0031753 | OH | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 163W00000X | RN.485598 | OH | N | Nursing Service Providers | Registered Nurse |
No ID Information.