Provider Demographics
NPI:1174098909
Name:MARTIN, CHAMA ALISHA (RN)
Entity type:Individual
Prefix:
First Name:CHAMA
Middle Name:ALISHA
Last Name:MARTIN
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:557 JOHN BAKER RD
Mailing Address - Street 2:
Mailing Address - City:FIELDALE
Mailing Address - State:VA
Mailing Address - Zip Code:24089-3340
Mailing Address - Country:US
Mailing Address - Phone:276-521-2697
Mailing Address - Fax:
Practice Address - Street 1:557 JOHN BAKER RD
Practice Address - Street 2:
Practice Address - City:FIELDALE
Practice Address - State:VA
Practice Address - Zip Code:24089-3340
Practice Address - Country:US
Practice Address - Phone:276-521-2697
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-08
Last Update Date:2018-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0001234575253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0725176520Medicaid