Healthcare Provider Details

I. General information

NPI: 1083422505
Provider Name (Legal Business Name): CETTA LYNN MARTIN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/30/2024
Last Update Date: 12/30/2024
Certification Date: 12/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4801 E LINWOOD BLVD
KANSAS CITY MO
64128-2226
US

IV. Provider business mailing address

5285 FOXRIDGE DR APT 201
MISSION KS
66202-4500
US

V. Phone/Fax

Practice location:
  • Phone: 816-861-4700
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC1600X
TaxonomyContinuing Education/Staff Development Registered Nurse
License Number40088
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: