Healthcare Provider Details

I. General information

NPI: 1649018946
Provider Name (Legal Business Name): ALEXIS CHARLENE MARTIRE CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/19/2024
Last Update Date: 07/19/2024
Certification Date: 07/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1601 GOLF COURSE RD
GRAND RAPIDS MN
55744-8648
US

IV. Provider business mailing address

1 5TH ST
NASHWAUK MN
55769-1143
US

V. Phone/Fax

Practice location:
  • Phone: 218-326-3401
  • Fax: 218-999-1461
Mailing address:
  • Phone: 218-259-2318
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number11805
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: