Healthcare Provider Details

I. General information

NPI: 1023156155
Provider Name (Legal Business Name): NANNETTE B MARTIN NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/01/2007
Last Update Date: 01/10/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2131 S 17TH ST
WILMINGTON NC
28401-7407
US

IV. Provider business mailing address

2131 S 17TH ST
WILMINGTON NC
28401-7407
US

V. Phone/Fax

Practice location:
  • Phone: 910-772-9202
  • Fax: 910-772-9452
Mailing address:
  • Phone: 910-772-9202
  • Fax: 910-772-9452

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number0300348
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: