Healthcare Provider Details

I. General information

NPI: 1124698204
Provider Name (Legal Business Name): ELANIE DESHEA MARTENS FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/30/2021
Last Update Date: 04/29/2026
Certification Date: 04/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3420 BRUCE RDG
CLOVER SC
29710-6018
US

IV. Provider business mailing address

3420 BRUCE RDG
CLOVER SC
29710-6018
US

V. Phone/Fax

Practice location:
  • Phone: 417-350-9775
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number30164
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: