=====================================================
General NPI Number Information
=====================================================
NPI Number | 1255963450
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TYSHAWN MARTIN LPN
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/06/2020
-----------------------------------------------------
Last Update Date | 02/06/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5202 PLUNKETT ST
-----------------------------------------------------
City | HOLLYWOOD
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33021-8023
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-788-7779
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5202 PLUNKETT ST
-----------------------------------------------------
City | HOLLYWOOD
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33021-8023
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-788-7779
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 171M00000X
-----------------------------------------------------
Taxonomy Name | Case Manager/Care Coordinator
-----------------------------------------------------
License Number | PN514280
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | PN514280
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 224P00000X
-----------------------------------------------------
Taxonomy Name | Prosthetist
-----------------------------------------------------
License Number | PN514280
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 246Y00000X
-----------------------------------------------------
Taxonomy Name | Health Information Specialist/Technologist
-----------------------------------------------------
License Number | PN514280
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #5
-----------------------------------------------------
Taxonomy Code | 251E00000X
-----------------------------------------------------
Taxonomy Name | Home Health Agency
-----------------------------------------------------
License Number | PN514280F
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #6
-----------------------------------------------------
Taxonomy Code | 251F00000X
-----------------------------------------------------
Taxonomy Name | Home Infusion Agency
-----------------------------------------------------
License Number | PN514280
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #7
-----------------------------------------------------
Taxonomy Code | 251J00000X
-----------------------------------------------------
Taxonomy Name | Nursing Care Agency
-----------------------------------------------------
License Number | PN514280
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #8
-----------------------------------------------------
Taxonomy Code | 405300000X
-----------------------------------------------------
Taxonomy Name | Prevention Professional
-----------------------------------------------------
License Number | PN514280
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #9
-----------------------------------------------------
Taxonomy Code | 164W00000X
-----------------------------------------------------
Taxonomy Name | Licensed Practical Nurse
-----------------------------------------------------
License Number | PN514280
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------