Provider Demographics
NPI:1598169302
Name:MARTIN, SUSAM ANN (RN, IBCLC)
Entity type:Individual
Prefix:
First Name:SUSAM
Middle Name:ANN
Last Name:MARTIN
Suffix:
Gender:F
Credentials:RN, IBCLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26 WILLOW ST
Mailing Address - Street 2:
Mailing Address - City:PELHAM
Mailing Address - State:NH
Mailing Address - Zip Code:03076-3128
Mailing Address - Country:US
Mailing Address - Phone:978-758-2325
Mailing Address - Fax:
Practice Address - Street 1:26 WILLOW ST
Practice Address - Street 2:
Practice Address - City:PELHAM
Practice Address - State:NH
Practice Address - Zip Code:03076-3128
Practice Address - Country:US
Practice Address - Phone:978-758-2325
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-22
Last Update Date:2014-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA10117450174N00000X
MARN164582163WL0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WL0100XNursing Service ProvidersRegistered NurseLactation Consultant
No174N00000XOther Service ProvidersLactation Consultant, Non-RN