Basic Information
Provider Information
NPI: 1053967653
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: MARTIN
FirstName: AVERY
MiddleName: JEA
NamePrefix:  
NameSuffix:  
Credential:  
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: PO BOX 635283
Address2:  
City: CINCINNATI
State: OH
PostalCode: 452635283
CountryCode: US
TelephoneNumber:  
FaxNumber:  
Practice Location
Address1: 405 VIOLET RD
Address2:  
City: CRITTENDEN
State: KY
PostalCode: 410308956
CountryCode: US
TelephoneNumber: 8594281610
FaxNumber: 8594283923
Other Information
ProviderEnumerationDate: 08/11/2019
LastUpdateDate: 09/24/2020
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate: 09/24/2020

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
363L00000XAPRN.CNP.024869OHN Physician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner 
363L00000X3013651KYY Physician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner 

No ID Information.


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