Provider Demographics
NPI:1699480921
Name:MARTIN, ELISSAH
Entity type:Individual
Prefix:
First Name:ELISSAH
Middle Name:
Last Name:MARTIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5166 WILDWOOD DR
Mailing Address - Street 2:
Mailing Address - City:SORRENTO
Mailing Address - State:LA
Mailing Address - Zip Code:70778-3430
Mailing Address - Country:US
Mailing Address - Phone:504-606-8331
Mailing Address - Fax:
Practice Address - Street 1:5166 WILDWOOD DR
Practice Address - Street 2:
Practice Address - City:SORRENTO
Practice Address - State:LA
Practice Address - Zip Code:70778-3430
Practice Address - Country:US
Practice Address - Phone:504-606-8331
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-20
Last Update Date:2023-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver