Healthcare Provider Details

I. General information

NPI: 1851373898
Provider Name (Legal Business Name): SANDRA L MARTIN NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/16/2005
Last Update Date: 03/30/2021
Certification Date: 03/30/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 NAVARRE PL SUITE 6600
SOUTH BEND IN
46601-1156
US

IV. Provider business mailing address

710 N NILES AVE
SOUTH BEND IN
46617-1924
US

V. Phone/Fax

Practice location:
  • Phone: 574-232-7227
  • Fax: 574-232-2064
Mailing address:
  • Phone: 574-647-1610
  • Fax: 574-237-6069

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number71001851A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: