Healthcare Provider Details

I. General information

NPI: 1619976933
Provider Name (Legal Business Name): TERI A MARTIN F.N.P.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/19/2005
Last Update Date: 06/08/2016
Certification Date:
Deactivation Date: 03/20/2006
Reactivation Date: 03/27/2006

III. Provider practice location address

600 ROE AVE
ELMIRA NY
14905-1629
US

IV. Provider business mailing address

571 SAINT JOSEPHS BLVD FL 2
ELMIRA NY
14901-3230
US

V. Phone/Fax

Practice location:
  • Phone: 607-737-4508
  • Fax: 607-735-5738
Mailing address:
  • Phone: 607-271-2050
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberF330978-1
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number330978
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: