Healthcare Provider Details

I. General information

NPI: 1396826681
Provider Name (Legal Business Name): L ELLEN MARTIN CNM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LESLIE ELLEN MARTIN

II. Dates (important events)

Enumeration Date: 10/17/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20 GLENLAKE PKWY
ATLANTA GA
30328
US

IV. Provider business mailing address

20 GLENLAKE PKWY
ATLANTA GA
30328
US

V. Phone/Fax

Practice location:
  • Phone: 770-677-6049
  • Fax: 770-677-7331
Mailing address:
  • Phone: 770-677-6049
  • Fax: 770-677-7331

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberRN041837
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: