Healthcare Provider Details

I. General information

NPI: 1871814152
Provider Name (Legal Business Name): TABATHA LYNN MARTINO LPN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MISS TABATHA LYNN PEASE

II. Dates (important events)

Enumeration Date: 06/21/2010
Last Update Date: 06/21/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

248 HIGH ST NW
EAST CANTON OH
44730-1032
US

IV. Provider business mailing address

248 HIGH ST NW
EAST CANTON OH
44730-1032
US

V. Phone/Fax

Practice location:
  • Phone: 330-268-7260
  • Fax:
Mailing address:
  • Phone: 330-268-7260
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License NumberPN135850IV
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: