Healthcare Provider Details

I. General information

NPI: 1598234437
Provider Name (Legal Business Name): TRACY LYNN MARTIN CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/21/2018
Last Update Date: 11/21/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

725 NORTH ST
PITTSFIELD MA
01201-4109
US

IV. Provider business mailing address

310 LAUREL ST
LEE MA
01238-9509
US

V. Phone/Fax

Practice location:
  • Phone: 413-447-2834
  • Fax:
Mailing address:
  • Phone: 413-464-5129
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number265195
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: