Healthcare Provider Details

I. General information

NPI: 1063946358
Provider Name (Legal Business Name): KIMBERLY CHARISE MARTIN NP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/13/2017
Last Update Date: 01/27/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1802 BRAEBURN DR
SALEM VA
24153-7357
US

IV. Provider business mailing address

2000 HEALTH PARK DR FL HP2
BRENTWOOD TN
37027-4692
US

V. Phone/Fax

Practice location:
  • Phone: 540-772-3400
  • Fax:
Mailing address:
  • Phone: 615-373-7600
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number0024174765
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number0024174765
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: