Provider Demographics
NPI:1699124586
Name:MARTIN, MICHELLE ANN (COA)
Entity type:Individual
Prefix:MRS
First Name:MICHELLE
Middle Name:ANN
Last Name:MARTIN
Suffix:
Gender:F
Credentials:COA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8817 N 83RD ST
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68122-2268
Mailing Address - Country:US
Mailing Address - Phone:402-707-2798
Mailing Address - Fax:402-391-1331
Practice Address - Street 1:8817 N 83RD ST
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68122-2268
Practice Address - Country:US
Practice Address - Phone:402-707-2798
Practice Address - Fax:402-391-1331
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-10
Last Update Date:2016-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE156525156FX1101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1101XEye and Vision Services ProvidersTechnician/TechnologistOphthalmic Assistant