=====================================================
General NPI Number Information
=====================================================
NPI Number | 1497163489
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | HEATHER MARTIN FNP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/23/2014
-----------------------------------------------------
Last Update Date | 09/20/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1968 N PEART RD STE 20
-----------------------------------------------------
City | CASA GRANDE
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85122-2497
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 480-214-9000
-----------------------------------------------------
Fax | 480-214-9999
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2051 W CHANDLER BLVD STE 5
-----------------------------------------------------
City | CHANDLER
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85224-6239
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 480-214-9000
-----------------------------------------------------
Fax | 480-214-9999
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LX0001X
-----------------------------------------------------
Taxonomy Name | Obstetrics & Gynecology Nurse Practitioner
-----------------------------------------------------
License Number | 266780
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | 266780
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 163W00000X
-----------------------------------------------------
Taxonomy Name | Registered Nurse
-----------------------------------------------------
License Number | RN168783
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------