MEDICARE: SHALETHA MARTIN NP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	904818	MS

General Provider Information

NPI Number	:	1659046399
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHALETHA MARTIN NP

Provider Business Mailing Address
First Line	:	2135 HENRY HILL DR
Second Line	:
City	:	JACKSON
State	:	MS
Zip	:	39204-2006
Country	:	US
Telephone Number	:	601-398-2335
Fax Number	:

Provider Business Practice Location Address
First Line	:	11273 HIGHWAY 61 N
Second Line	:
City	:	ROBINSONVILLE
State	:	MS
Zip	:	38664-9705
Country	:	US
Telephone Number	:	662-363-3224
Fax Number	:	662-363-3234

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/13/2021
Last Update Date	:	09/19/2022

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