Healthcare Provider Details

I. General information

NPI: 1679238877
Provider Name (Legal Business Name): CARLY MARTIN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/02/2021
Last Update Date: 11/02/2021
Certification Date: 11/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1029 PLEASANT ST
BRIDGEWATER MA
02324-2472
US

IV. Provider business mailing address

250 1ST AVE UNIT 532
CHARLESTOWN MA
02129-4412
US

V. Phone/Fax

Practice location:
  • Phone: 508-697-8116
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License NumberRN2309864
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: