Healthcare Provider Details

I. General information

NPI: 1609313311
Provider Name (Legal Business Name): MARY A MARTIN NP BC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/20/2017
Last Update Date: 01/20/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10430 HADDINGTON DR NW
CHARLOTTE NC
28269-6955
US

IV. Provider business mailing address

6809 FAIRVIEW RD
CHARLOTTE NC
28210-4195
US

V. Phone/Fax

Practice location:
  • Phone: 704-200-1122
  • Fax: 704-464-1781
Mailing address:
  • Phone: 704-200-1122
  • Fax: 704-464-1781

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number5002313
License Number StateNC

VIII. Authorized Official

Name: MARY ANN MARTIN
Title or Position: PSYCHIATRIC NURSE PRACTITIONER OWNE
Credential: NP
Phone: 704-200-1122