Provider Demographics
NPI:1871325332
Name:MARTIN, CARLA SUZANNE
Entity type:Individual
Prefix:
First Name:CARLA
Middle Name:SUZANNE
Last Name:MARTIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8677 SUMMIT PEAK WAY APT 203
Mailing Address - Street 2:
Mailing Address - City:OOLTEWAH
Mailing Address - State:TN
Mailing Address - Zip Code:37363-3157
Mailing Address - Country:US
Mailing Address - Phone:706-996-1154
Mailing Address - Fax:
Practice Address - Street 1:8677 SUMMIT PEAK WAY APT 203
Practice Address - Street 2:
Practice Address - City:OOLTEWAH
Practice Address - State:TN
Practice Address - Zip Code:37363-3157
Practice Address - Country:US
Practice Address - Phone:706-996-1154
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-14
Last Update Date:2024-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN148528128347C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes347C00000XTransportation ServicesPrivate Vehicle