Basic Information
| Provider Information | |||||||||
| NPI: | 1053967653 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MARTIN | ||||||||
| FirstName: | AVERY | ||||||||
| MiddleName: | JEA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 635283 | ||||||||
| Address2: | |||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452635283 | ||||||||
| CountryCode: | US | ||||||||
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| 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 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/24/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 3013651 | KY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363L00000X | APRN.CNP.024869 | OH | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.