Healthcare Provider Details

I. General information

NPI: 1952072571
Provider Name (Legal Business Name): KOURTNEY MARTIN CNM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/23/2021
Last Update Date: 12/21/2023
Certification Date: 10/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1560 KINGSLEY AVE STE 4
ORANGE PARK FL
32073-9200
US

IV. Provider business mailing address

197 N LAKE CUNNINGHAM AVE
JACKSONVILLE FL
32259-7939
US

V. Phone/Fax

Practice location:
  • Phone: 904-264-1628
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code176B00000X
TaxonomyMidwife
License Number11015562
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code367A00000X
TaxonomyAdvanced Practice Midwife
License Number4010884
License Number StateKY
# 3
Primary TaxonomyY
Taxonomy Code367A00000X
TaxonomyAdvanced Practice Midwife
License Number11015562
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: