Healthcare Provider Details

I. General information

NPI: 1700971231
Provider Name (Legal Business Name): MONIQUE MARTY FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/03/2006
Last Update Date: 11/05/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

403 N STATE OF FRANKLIN RD
JOHNSON CITY TN
37604-6034
US

IV. Provider business mailing address

1021 W OAKLAND AVE SUITE 207
JOHNSON CITY TN
37604-2191
US

V. Phone/Fax

Practice location:
  • Phone: 423-431-7111
  • Fax: 423-431-7092
Mailing address:
  • Phone: 423-916-5106
  • Fax: 423-952-3109

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberRN114496
License Number StateTN
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPN10995
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: