Healthcare Provider Details

I. General information

NPI: 1841579927
Provider Name (Legal Business Name): ALICIA LESLIE MARTIN C-NPT, NNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/08/2011
Last Update Date: 10/03/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1235 E CHEROKEE ST NEONATAL INTENSIVE CARE UNIT
SPRINGFIELD MO
65804-2203
US

IV. Provider business mailing address

1235 E CHEROKEE ST NEONATAL INTENSIVE CARE UNIT
SPRINGFIELD MO
65804-2203
US

V. Phone/Fax

Practice location:
  • Phone: 417-820-2891
  • Fax: 417-820-7850
Mailing address:
  • Phone: 417-820-2891
  • Fax: 417-820-7850

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LN0000X
TaxonomyNeonatal Nurse Practitioner
License Number2011027231
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: