Healthcare Provider Details

I. General information

NPI: 1699480921
Provider Name (Legal Business Name): ELISSAH MARTIN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/20/2023
Last Update Date: 08/11/2023
Certification Date: 08/01/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5166 WILDWOOD DR
SORRENTO LA
70778-3430
US

IV. Provider business mailing address

5166 WILDWOOD DR
SORRENTO LA
70778-3430
US

V. Phone/Fax

Practice location:
  • Phone: 504-606-8331
  • Fax:
Mailing address:
  • Phone: 504-606-8331
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172A00000X
TaxonomyDriver
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: