Basic Information
| Provider Information | |||||||||
| NPI: | 1003027228 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MARTINDALE | ||||||||
| FirstName: | SEAN | ||||||||
| MiddleName: | F | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | APRN, FNP-C, CRNFA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 950244 | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402950244 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5029534700 | ||||||||
| FaxNumber: | 5029534798 | ||||||||
| Practice Location | |||||||||
| Address1: | 2215 PORTLAND AVE | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402121033 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5027748631 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/28/2007 | ||||||||
| LastUpdateDate: | 07/15/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 07/15/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WR0006X | 1090199 | KY | N | Nursing Service Providers | Registered Nurse | Registered Nurse First Assistant | 363L00000X | 3010370 | KY | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363LF0000X | 28143085A | IN | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LF0000X | 3010370 | KY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 7100424600 | 05 | KY | MEDICAID |