Provider Demographics
NPI:1184785115
Name:MARTIN, LISA JANE (CNS ARNP)
Entity type:Individual
Prefix:MS
First Name:LISA
Middle Name:JANE
Last Name:MARTIN
Suffix:
Gender:F
Credentials:CNS ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3791 STATE ROUTE 63
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:OH
Mailing Address - Zip Code:45036-9371
Mailing Address - Country:US
Mailing Address - Phone:513-932-1211
Mailing Address - Fax:513-932-2666
Practice Address - Street 1:3791 STATE ROUTE 63
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:OH
Practice Address - Zip Code:45036-9371
Practice Address - Country:US
Practice Address - Phone:513-932-1211
Practice Address - Fax:513-932-2666
Is Sole Proprietor?:No
Enumeration Date:2006-12-13
Last Update Date:2012-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYKYARNP2789S363LP0808X, 364SP0808X
OHRX11806364SP0809X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SP0809XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health, Adult
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No364SP0808XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY78003522Medicaid
KY78003522Medicaid
0726301Medicare ID - Type Unspecified