Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 363LW0102X | Nurse Practitioner - Women's Health | 71001625A | IN |
NPI | 1003851874 |
---|---|
Provider Name | Rhea Martin |
First Address | Detroit, MI 48278-1076 |
Second Address | Crown Point, IN 46307-3676 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 17/06/2006 |
Last Update Date | 13/03/2021 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
000000480735 | ANTHEM PIN (01) | IN |
000000721669 | ANTHEM TRADITIONAL (01) | IN |
200818070 | (05) | IN |