Healthcare Provider Details

I. General information

NPI: 1972068930
Provider Name (Legal Business Name): NICOLE MARIE MARTIN CRNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/04/2019
Last Update Date: 08/07/2024
Certification Date: 08/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5 S WASHINGTON AVE
JERMYN PA
18433-1121
US

IV. Provider business mailing address

311 OAK ST
DURYEA PA
18642-1909
US

V. Phone/Fax

Practice location:
  • Phone: 570-417-8407
  • Fax:
Mailing address:
  • Phone: 570-417-8407
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License NumberSP019951
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN11017188
License Number StateFL

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: