Healthcare Provider Details

I. General information

NPI: 1134951700
Provider Name (Legal Business Name): TARA MITCHELL MARTINO MSN, RN, PMHNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/14/2024
Last Update Date: 10/05/2026
Certification Date: 10/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

225 NEWMAN AVE STE 315
RUMFORD RI
02916-1218
US

IV. Provider business mailing address

225 NEWMAN AVE STE 315
RUMFORD RI
02916-1218
US

V. Phone/Fax

Practice location:
  • Phone: 774-264-3965
  • Fax:
Mailing address:
  • Phone: 774-264-3965
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberAPRN04628
License Number StateRI
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN79538
License Number StateRI
# 3
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN2293881
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: