Healthcare Provider Details

I. General information

NPI: 1871557058
Provider Name (Legal Business Name): JACKIE BRATTON MARTIN RNC, MS, NNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/14/2006
Last Update Date: 07/30/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1906 BELLEVIEW AVE SE
ROANOKE VA
24014-1838
US

IV. Provider business mailing address

141 HILLVIEW DR
ROANOKE VA
24019-8070
US

V. Phone/Fax

Practice location:
  • Phone: 540-981-8124
  • Fax: 540-983-1243
Mailing address:
  • Phone: 540-977-2022
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LN0000X
TaxonomyNeonatal Nurse Practitioner
License Number0017137194
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: