Healthcare Provider Details

I. General information

NPI: 1699723254
Provider Name (Legal Business Name): PATTI L MARTIN NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/05/2006
Last Update Date: 06/16/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3333 W DEYOUNG ST
MARION IL
62959-5884
US

IV. Provider business mailing address

4750 HEMPSTEAD STATION DR
KETTERING OH
45429-5164
US

V. Phone/Fax

Practice location:
  • Phone: 618-998-7000
  • Fax:
Mailing address:
  • Phone: 800-875-0136
  • Fax: 937-619-4231

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number209000493
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: