Healthcare Provider Details

I. General information

NPI: 1588869804
Provider Name (Legal Business Name): LISA ANNE MARTIN ATC, CSCS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/18/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8227 NORTHWEST BLVD SUITE 160
INDIANAPOLIS IN
46278-1387
US

IV. Provider business mailing address

8640 INGALLS LN
CAMBY IN
46113-8116
US

V. Phone/Fax

Practice location:
  • Phone: 317-415-5747
  • Fax:
Mailing address:
  • Phone: 317-821-1668
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number36000417A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: