Healthcare Provider Details

I. General information

NPI: 1679390645
Provider Name (Legal Business Name): ELIZABETH KATHRYN MARTIN NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/23/2024
Last Update Date: 09/04/2026
Certification Date: 09/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1010 E WEST MAPLE RD STE 100
WALLED LAKE MI
48390-3571
US

IV. Provider business mailing address

3247 GREEN OAKS DR
WEST BLOOMFIELD MI
48324-3209
US

V. Phone/Fax

Practice location:
  • Phone: 248-313-2900
  • Fax:
Mailing address:
  • Phone: 248-217-3592
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number4704270630
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: