Healthcare Provider Details

I. General information

NPI: 1003363201
Provider Name (Legal Business Name): SHELLEY CHARMAINE MARTIN CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SHELLEY CHARMAINE DAY

II. Dates (important events)

Enumeration Date: 09/06/2016
Last Update Date: 12/12/2023
Certification Date: 12/12/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1240 JESSE JEWELL PKWY SE STE 500
GAINESVILLE GA
30501-3861
US

IV. Provider business mailing address

1240 JESSE JEWELL PKWY SE STE 500
GAINESVILLE GA
30501-3861
US

V. Phone/Fax

Practice location:
  • Phone: 770-536-9864
  • Fax: 770-297-5025
Mailing address:
  • Phone: 770-536-9864
  • Fax: 770-297-5025

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number1-086060
License Number StateAL
# 2
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number1-086060
License Number StateAL
# 3
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberGAA-NP001186
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: