Provider Demographics
NPI:1366932139
Name:MARTIN, MEGAN JEAN (FNP)
Entity type:Individual
Prefix:
First Name:MEGAN
Middle Name:JEAN
Last Name:MARTIN
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:MEGAN
Other - Middle Name:JEAN
Other - Last Name:LONG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:70 JOHN M BOOR DR
Mailing Address - Street 2:
Mailing Address - City:GILBERTS
Mailing Address - State:IL
Mailing Address - Zip Code:60136-4063
Mailing Address - Country:US
Mailing Address - Phone:224-629-6941
Mailing Address - Fax:815-748-3070
Practice Address - Street 1:2560 HAUSER ROSS DR STE 450
Practice Address - Street 2:
Practice Address - City:SYCAMORE
Practice Address - State:IL
Practice Address - Zip Code:60178-3185
Practice Address - Country:US
Practice Address - Phone:815-748-3040
Practice Address - Fax:815-748-3070
Is Sole Proprietor?:No
Enumeration Date:2018-05-16
Last Update Date:2018-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209.017663363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily