Healthcare Provider Details

I. General information

NPI: 1578550935
Provider Name (Legal Business Name): MARYANN MARTIN N.P.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/30/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1051 PORT MALABAR BLVD NE SUITE 6, PORT MALABAR PROFESSIONAL BLDG
PALM BAY FL
32905-5153
US

IV. Provider business mailing address

1051 PORT MALABAR BLVD NE SUITE 6, PORT MALABAR PROFESSIONAL BLDG
PALM BAY FL
32905-5153
US

V. Phone/Fax

Practice location:
  • Phone: 321-727-9063
  • Fax:
Mailing address:
  • Phone: 321-727-9063
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License NumberARNP9168017
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: