Healthcare Provider Details

I. General information

NPI: 1679521520
Provider Name (Legal Business Name): MICHELLE RENEE MARTIN PNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/04/2006
Last Update Date: 09/24/2026
Certification Date: 09/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1032 CROSSWINDS CT
WENTZVILLE MO
63385-4836
US

IV. Provider business mailing address

1032 CROSSWINDS CT
WENTZVILLE MO
63385-4836
US

V. Phone/Fax

Practice location:
  • Phone: 844-853-8937
  • Fax: 636-332-1401
Mailing address:
  • Phone: 844-853-8937
  • Fax: 636-332-1401

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WP0200X
TaxonomyPediatric Registered Nurse
License Number131957
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number131957
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: