Healthcare Provider Details

I. General information

NPI: 1407209075
Provider Name (Legal Business Name): MIRENDA MARTIN APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/19/2016
Last Update Date: 07/19/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

507 N MAIN STREET SALEM FAMILY CLINIC 507 N MAIN STREET
SALEM AR
72576
US

IV. Provider business mailing address

PO BOX 189 PO BOX 189
SALEM AR
72576-0189
US

V. Phone/Fax

Practice location:
  • Phone: 870-895-2541
  • Fax:
Mailing address:
  • Phone: 870-895-2541
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code364SF0001X
TaxonomyFamily Health Clinical Nurse Specialist
License NumberA004739
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: