Provider Demographics
NPI:1992976492
Name:MARTIN, MICHELE MARIE (APRN)
Entity type:Individual
Prefix:MRS
First Name:MICHELE
Middle Name:MARIE
Last Name:MARTIN
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19326 BARON RD
Mailing Address - Street 2:
Mailing Address - City:MOKENA
Mailing Address - State:IL
Mailing Address - Zip Code:60448-9288
Mailing Address - Country:US
Mailing Address - Phone:708-684-7045
Mailing Address - Fax:708-684-7040
Practice Address - Street 1:19326 BARON RD
Practice Address - Street 2:
Practice Address - City:MOKENA
Practice Address - State:IL
Practice Address - Zip Code:60448-9288
Practice Address - Country:US
Practice Address - Phone:708-684-7045
Practice Address - Fax:708-684-7040
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-12
Last Update Date:2008-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL364S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364S00000XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse Specialist