Healthcare Provider Details

I. General information

NPI: 1447244504
Provider Name (Legal Business Name): AMY G MARTIN APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/06/2005
Last Update Date: 09/03/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

345 MONTAUK AVE
NEW LONDON CT
06320-4738
US

IV. Provider business mailing address

345 MONTAUK AVE
NEW LONDON CT
06320-4738
US

V. Phone/Fax

Practice location:
  • Phone: 860-444-6868
  • Fax: 860-437-0650
Mailing address:
  • Phone: 860-444-6868
  • Fax: 860-437-0650

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License Number001886
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: