Provider Demographics
NPI:1295495802
Name:MARTIN, MICHELLE ELAINE (LPN)
Entity type:Individual
Prefix:MRS
First Name:MICHELLE
Middle Name:ELAINE
Last Name:MARTIN
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:175 WATERLOO ST
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:WI
Mailing Address - Zip Code:53925-1764
Mailing Address - Country:US
Mailing Address - Phone:608-695-0594
Mailing Address - Fax:
Practice Address - Street 1:1515 HOMMEN RD
Practice Address - Street 2:
Practice Address - City:DEERFIELD
Practice Address - State:WI
Practice Address - Zip Code:53531-9678
Practice Address - Country:US
Practice Address - Phone:608-444-0774
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-22
Last Update Date:2021-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI301758164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse