Healthcare Provider Details

I. General information

NPI: 1588080121
Provider Name (Legal Business Name): SUSAN ANITA MARTIN FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/06/2014
Last Update Date: 03/26/2024
Certification Date: 03/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

PINE KNOLL ASSISTED LIVING 607 WILSON CREEK RD.
LAWRENCEBURG IN
47025
US

IV. Provider business mailing address

7655 STATE ROAD 48
AURORA IN
47001-8987
US

V. Phone/Fax

Practice location:
  • Phone: 812-537-4422
  • Fax:
Mailing address:
  • Phone: 812-290-1611
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number71004884A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number71004884A
License Number StateIN
# 3
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number28143926A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: