Healthcare Provider Details

I. General information

NPI: 1558094748
Provider Name (Legal Business Name): KELLI B MARTIN CRNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/05/2022
Last Update Date: 11/29/2022
Certification Date: 11/29/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

901 LEIGHTON AVE STE 101
ANNISTON AL
36207-5703
US

IV. Provider business mailing address

901 LEIGHTON AVE STE 101
ANNISTON AL
36207-5703
US

V. Phone/Fax

Practice location:
  • Phone: 256-236-0890
  • Fax: 256-236-7078
Mailing address:
  • Phone: 256-236-0890
  • Fax: 256-236-7078

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number1-118739
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: