=====================================================
General NPI Number Information
=====================================================
NPI Number | 1083011274
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CARMEN I JOHNSON-MARTELL DNP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/03/2014
-----------------------------------------------------
Last Update Date | 09/05/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2016 25TH ST
-----------------------------------------------------
City | NEWPORT NEWS
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23607-5512
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 757-915-5781
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 521 EATON ST
-----------------------------------------------------
City | HAMPTON
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23669-3128
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-922-2435
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | 0024173716
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------