Healthcare Provider Details

I. General information

NPI: 1639123763
Provider Name (Legal Business Name): KATHLEEN ANN MARTIN APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/22/2006
Last Update Date: 11/22/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 MEDICAL CENTER DR DEPT OF CARDIOLOGY
LEBANON NH
03756-1000
US

IV. Provider business mailing address

1 MEDICAL CENTER DR DEPT OF CARDIOLOGY
LEBANON NH
03756-1000
US

V. Phone/Fax

Practice location:
  • Phone: 603-650-7756
  • Fax: 603-650-5267
Mailing address:
  • Phone: 603-650-7756
  • Fax: 603-650-5267

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number052389-23-12
License Number StateNH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: