MEDICARE: KELLY ELIZABETH MARTIN APRN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	2022016427	MO

General Provider Information

NPI Number	:	1285413880
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KELLY ELIZABETH MARTIN APRN

Provider Business Mailing Address
First Line	:	2020 MERLIN DR
Second Line	:
City	:	HARKER HEIGHTS
State	:	TX
Zip	:	76548-2527
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2020 MERLIN DR
Second Line	:
City	:	HARKER HEIGHTS
State	:	TX
Zip	:	76548-2527
Country	:	US
Telephone Number	:	501-712-6209
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/25/2023
Last Update Date	:	09/25/2023

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