Provider Demographics
NPI:1245227313
Name:MARTIN, SUSAN C (FNP-BC)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:C
Last Name:MARTIN
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1385 S HIGHLAND AVE STE B1
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:TN
Mailing Address - Zip Code:38301-7547
Mailing Address - Country:US
Mailing Address - Phone:314-270-4707
Mailing Address - Fax:731-427-0995
Practice Address - Street 1:1385 S HIGHLAND AVE STE B1
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:TN
Practice Address - Zip Code:38301-7547
Practice Address - Country:US
Practice Address - Phone:314-270-4707
Practice Address - Fax:731-427-0995
Is Sole Proprietor?:No
Enumeration Date:2005-10-04
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNAPN11327363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3709355Medicaid
TN3709355Medicaid
Q46885Medicare UPIN
3640928Medicare ID - Type Unspecified
MM1259779OtherDEA NUMBER
TN3709355Medicaid