Healthcare Provider Details

I. General information

NPI: 1104387695
Provider Name (Legal Business Name): CHATINA SPEARS MARTIN NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/27/2019
Last Update Date: 03/23/2026
Certification Date: 03/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7112 S SIWELL RD STE C
BYRAM MS
39272-8744
US

IV. Provider business mailing address

308 MELBA HILL DR
JACKSON MS
39209-2833
US

V. Phone/Fax

Practice location:
  • Phone: 601-398-2847
  • Fax: 601-510-3883
Mailing address:
  • Phone: 601-622-5620
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number903055
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: