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General NPI Number Information
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NPI Number | 1609313311
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Entity Type | Organization
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Legal Business Name | MARY A MARTIN NP BC
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Dates
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Enumeration Date | 01/20/2017
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Last Update Date | 01/20/2017
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Provider Practice Location Address
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Address Line | 10430 HADDINGTON DR NW
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City | CHARLOTTE
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State | NC
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Zip | 28269-6955
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Country | US
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Telephone | 704-200-1122
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Fax | 704-464-1781
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Provider Business Mailing Address
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Address Line | 6809 FAIRVIEW RD
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City | CHARLOTTE
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State | NC
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Zip | 28210-4195
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Country | US
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Telephone | 704-200-1122
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Fax | 704-464-1781
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Authorized Official
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Title or Position | PSYCHIATRIC NURSE PRACTITIONER OWNE
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Name | MARY ANN MARTIN
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Credential | NP
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Telephone | 704-200-1122
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM0850X
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Taxonomy Name | Adult Mental Health Clinic/Center
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License Number | 5002313
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License Number State | NC
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