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General NPI Number Information
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NPI Number | 1275060907
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Entity Type | Individual
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Provider Name | MARY MARTIN AGACNP-BC
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Gender | Female
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Dates
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Enumeration Date | 05/12/2017
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Last Update Date | 05/12/2017
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Provider Practice Location Address
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Address Line | 615 S NEW BALLAS RD
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City | SAINT LOUIS
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State | MO
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Zip | 63141-8221
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Country | US
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Telephone | 636-237-4132
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Fax |
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Provider Business Mailing Address
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Address Line | 615 SOUTH NEW BALLAS
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City | ST. LOUIS
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State | MO
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Zip | 63143
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Country | US
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Telephone | 314-974-6874
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LA2100X
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Taxonomy Name | Acute Care Nurse Practitioner
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License Number | 2017008673
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License Number State | MO
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