Provider Demographics
NPI:1003363201
Name:MARTIN, SHELLEY CHARMAINE (CNP)
Entity Type:Individual
Prefix:
First Name:SHELLEY
Middle Name:CHARMAINE
Last Name:MARTIN
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:SHELLEY
Other - Middle Name:CHARMAINE
Other - Last Name:DAY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1240 JESSE JEWELL PKWY SE STE 500
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30501-3861
Mailing Address - Country:US
Mailing Address - Phone:770-536-9864
Mailing Address - Fax:770-297-5025
Practice Address - Street 1:1240 JESSE JEWELL PKWY SE STE 500
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:30501-3861
Practice Address - Country:US
Practice Address - Phone:770-536-9864
Practice Address - Fax:770-297-5025
Is Sole Proprietor?:No
Enumeration Date:2016-09-06
Last Update Date:2023-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-086060363L00000X, 363LG0600X
GAGAA-NP001186363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL226376Medicaid
AL102I504651OtherMEDICARE
AL226376Medicaid
AL4974542OtherAETNA
ALP01791897OtherRR MEDICARE
AL192988Medicaid
AL6236875OtherUHC
AL221846Medicaid
AL511-85553OtherBCBS
AL222311Medicaid
AL512-05412OtherBCBS
ALZ79211OtherVIVA HEALTH
MS01551240OtherMS MEDICAID
AL215202Medicaid
AL511-85555OtherBCBS
AL512-05413OtherBCBS