Healthcare Provider Details

I. General information

NPI: 1518307487
Provider Name (Legal Business Name): KATHLEEN MARTIN CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KATHLEEN GRAHAM RN

II. Dates (important events)

Enumeration Date: 06/25/2013
Last Update Date: 05/27/2020
Certification Date: 05/27/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3850 S NATIONAL AVE SUITE 600
SPRINGFIELD MO
65807-5287
US

IV. Provider business mailing address

3850 S NATIONAL AVE SUITE 600
SPRINGFIELD MO
65807-5287
US

V. Phone/Fax

Practice location:
  • Phone: 417-882-4880
  • Fax: 417-882-7843
Mailing address:
  • Phone: 417-882-4880
  • Fax: 417-882-7843

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number2013019751
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number2013019751
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: