Healthcare Provider Details

I. General information

NPI: 1144981531
Provider Name (Legal Business Name): CELEISHA MARTIN FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/06/2022
Last Update Date: 02/08/2023
Certification Date: 02/08/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1107A BROOKDALE ST
MARTINSVILLE VA
24112-4501
US

IV. Provider business mailing address

213 S JEFFERSON ST STE 1006
ROANOKE VA
24011-1713
US

V. Phone/Fax

Practice location:
  • Phone: 276-670-3300
  • Fax: 276-634-0379
Mailing address:
  • Phone: 540-224-5352
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number0024183384
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number0024183384
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: