Healthcare Provider Details

I. General information

NPI: 1205902624
Provider Name (Legal Business Name): MARY ELIZABETH MARTIN RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/28/2006
Last Update Date: 07/30/2023
Certification Date: 07/30/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

595 W MAIN ST
WATERTOWN NY
13601-1335
US

IV. Provider business mailing address

463 SCOTT RD
SANDY CREEK NY
13145-2154
US

V. Phone/Fax

Practice location:
  • Phone: 315-888-2228
  • Fax:
Mailing address:
  • Phone: 315-387-6683
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number260901
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code163WA0400X
TaxonomyAddiction (Substance Use Disorder) Registered Nurse
License Number843451
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: