MEDICARE: DINA MARIE MARTIN RN, AGNP

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	363LG0600X	Gerontology Nurse Practitioner	AG08190135	SC

General Provider Information

NPI Number	:	1306497557
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DINA MARIE MARTIN RN, AGNP

Provider Business Mailing Address
First Line	:	PO BOX 609
Second Line	:
City	:	LEXINGTON
State	:	SC
Zip	:	29071-0609
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	171 MONROE LN
Second Line	:
City	:	LEXINGTON
State	:	SC
Zip	:	29072-3904
Country	:	US
Telephone Number	:	803-957-0500
Fax Number	:

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

Provider Enumeration Date	:	09/27/2019
Last Update Date	:	10/15/2021

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