Healthcare Provider Details

I. General information

NPI: 1063403418
Provider Name (Legal Business Name): KATHY MARTIN M.S.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/03/2005
Last Update Date: 06/25/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

315 S PEARL AVE
JOPLIN MO
64801
US

IV. Provider business mailing address

315 S PEARL AVE
JOPLIN MO
64801-2538
US

V. Phone/Fax

Practice location:
  • Phone: 417-781-6228
  • Fax: 417-781-6248
Mailing address:
  • Phone: 417-781-6228
  • Fax: 417-781-6248

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number2004008789
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number2005035596
License Number StateMO
# 3
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number2005035596
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: