Provider Demographics
NPI:1053967653
Name:MARTIN, AVERY JEA
Entity type:Individual
Prefix:
First Name:AVERY
Middle Name:JEA
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:PO BOX 635283
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45263-5283
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:405 VIOLET RD
Practice Address - Street 2:
Practice Address - City:CRITTENDEN
Practice Address - State:KY
Practice Address - Zip Code:41030-8956
Practice Address - Country:US
Practice Address - Phone:859-428-1610
Practice Address - Fax:859-428-3923
Is Sole Proprietor?:No
Enumeration Date:2019-08-11
Last Update Date:2020-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3013651363L00000X
OHAPRN.CNP.024869363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner