MEDICARE: KARLY MARTIN

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	390200000X	Student in an Organized Health Care Education/Training Program	245842	SC
2	363LF0000X	Family Nurse Practitioner	27619	SC

General Provider Information

NPI Number	:	1417631490
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KARLY MARTIN

Provider Business Mailing Address
First Line	:	PO BOX 6069
Second Line	:
City	:	WEST COLUMBIA
State	:	SC
Zip	:	29171-6069
Country	:	US
Telephone Number	:	803-791-2000
Fax Number	:

Provider Business Practice Location Address
First Line	:	5143 FOREST DR STE 20
Second Line	:
City	:	COLUMBIA
State	:	SC
Zip	:	29206-4918
Country	:	US
Telephone Number	:	803-314-9120
Fax Number	:

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

Provider Enumeration Date	:	06/12/2023
Last Update Date	:	04/17/2024

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Directions to “ KARLY MARTIN ” Practice Location

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