Provider Demographics
NPI:1194910042
Name:MARTIN, JANELL DIANNE (CRNA)
Entity type:Individual
Prefix:
First Name:JANELL
Middle Name:DIANNE
Last Name:MARTIN
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:JANELL
Other - Middle Name:DIANNE
Other - Last Name:WALDEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNA
Mailing Address - Street 1:PO BOX 551
Mailing Address - Street 2:
Mailing Address - City:HANNIBAL
Mailing Address - State:MO
Mailing Address - Zip Code:63401-0551
Mailing Address - Country:US
Mailing Address - Phone:573-248-5115
Mailing Address - Fax:573-248-5196
Practice Address - Street 1:6000 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:HANNIBAL
Practice Address - State:MO
Practice Address - Zip Code:63401-6887
Practice Address - Country:US
Practice Address - Phone:573-248-1300
Practice Address - Fax:573-248-5196
Is Sole Proprietor?:No
Enumeration Date:2007-09-12
Last Update Date:2019-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COSRA 100003367500000X
MO093508367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO71438530Medicaid
COCOA105387Medicare PIN