=====================================================
General NPI Number Information
=====================================================
NPI Number | 1740327329
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KELLIE DAVIS MARTINEZ FNP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/31/2007
-----------------------------------------------------
Last Update Date | 06/26/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9900 BREN RD E
-----------------------------------------------------
City | MINNETONKA
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55343-9664
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 828-855-8466
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1491 BERKSHIRE DR
-----------------------------------------------------
City | NEWTON
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28658-1970
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 828-855-8466
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363L00000X
-----------------------------------------------------
Taxonomy Name | Nurse Practitioner
-----------------------------------------------------
License Number | 0050-02519
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | 9700726
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------