Healthcare Provider Details

I. General information

NPI: 1356933360
Provider Name (Legal Business Name): DEIRDRA V MARTIN CRNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/10/2021
Last Update Date: 07/30/2026
Certification Date: 07/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 S. TWINING STREET, BLDG 760
MAXWELL AFB AL
36112-6219
US

IV. Provider business mailing address

300 SOUTH TWINING STREET, BLDG 760
MAXWELL AFB AL
36112-6219
US

V. Phone/Fax

Practice location:
  • Phone: 334-953-5200
  • Fax: 334-953-8607
Mailing address:
  • Phone: 334-953-5200
  • Fax: 334-953-8607

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number1-149010
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: