Provider Demographics
NPI:1659129781
Name:MARTIN, TAMARA KAE
Entity type:Individual
Prefix:
First Name:TAMARA
Middle Name:KAE
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 1:110 GRAND AVE UNIT C
Mailing Address - Street 2:
Mailing Address - City:RUSSELLS POINT
Mailing Address - State:OH
Mailing Address - Zip Code:43348-8501
Mailing Address - Country:US
Mailing Address - Phone:937-441-6708
Mailing Address - Fax:
Practice Address - Street 1:11691 CHANNEL VIEW DR
Practice Address - Street 2:
Practice Address - City:LAKEVIEW
Practice Address - State:OH
Practice Address - Zip Code:43331-9208
Practice Address - Country:US
Practice Address - Phone:937-441-6708
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-13
Last Update Date:2024-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide