Healthcare Provider Details

I. General information

NPI: 1033939764
Provider Name (Legal Business Name): KELLY MARIE MARTIN APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/16/2024
Last Update Date: 10/16/2024
Certification Date: 10/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

455 PINELLAS ST STE 400
CLEARWATER FL
33756-3356
US

IV. Provider business mailing address

577 NORMANDY RD
MADEIRA BEACH FL
33708-2315
US

V. Phone/Fax

Practice location:
  • Phone: 727-445-1911
  • Fax:
Mailing address:
  • Phone: 954-849-0254
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number11035940
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: