MEDICARE: JOHNNA ROSE MARTIN PMHNP-BC

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	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	F405320	NY

General Provider Information

NPI Number	:	1538931209
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JOHNNA ROSE MARTIN PMHNP-BC

Provider Business Mailing Address
First Line	:	828 E 149TH ST
Second Line	:
City	:	BRONX
State	:	NY
Zip	:	10455-4670
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	828 E 149TH ST
Second Line	:
City	:	BRONX
State	:	NY
Zip	:	10455-4670
Country	:	US
Telephone Number	:	347-431-0154
Fax Number	:

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

Provider Enumeration Date	:	10/26/2023
Last Update Date	:	10/26/2023

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