Healthcare Provider Details

I. General information

NPI: 1184779431
Provider Name (Legal Business Name): MARTI MELINDA MARTIN CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/25/2007
Last Update Date: 11/06/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3421 MEDICAL PARK DR.
MONROE LA
71203
US

IV. Provider business mailing address

1687 HIGHWAY 80 E
CALHOUN LA
71225-9122
US

V. Phone/Fax

Practice location:
  • Phone: 318-388-7890
  • Fax:
Mailing address:
  • Phone: 318-397-4092
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number01492
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: