Provider Demographics
NPI:1386497865
Name:MARTIN, LEELLON LOUISE (NP)
Entity type:Individual
Prefix:MRS
First Name:LEELLON
Middle Name:LOUISE
Last Name:MARTIN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5831 PORT HAVEN RD
Mailing Address - Street 2:
Mailing Address - City:MILLINGTON
Mailing Address - State:TN
Mailing Address - Zip Code:38053-8413
Mailing Address - Country:US
Mailing Address - Phone:901-849-4108
Mailing Address - Fax:
Practice Address - Street 1:5831 PORT HAVEN RD
Practice Address - Street 2:
Practice Address - City:MILLINGTON
Practice Address - State:TN
Practice Address - Zip Code:38053-8413
Practice Address - Country:US
Practice Address - Phone:901-849-4108
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-08
Last Update Date:2024-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN36006363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology