Provider Demographics
NPI:1275567554
Name:MARTIN, HEATHER
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:
Last Name:MARTIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:34444 KING STREET ROW
Mailing Address - Street 2:SUITE 4B
Mailing Address - City:LEWES
Mailing Address - State:DE
Mailing Address - Zip Code:19958-4787
Mailing Address - Country:US
Mailing Address - Phone:302-644-2773
Mailing Address - Fax:
Practice Address - Street 1:34444 KING STREET ROW
Practice Address - Street 2:SUITE 4B
Practice Address - City:LEWES
Practice Address - State:DE
Practice Address - Zip Code:19958-4787
Practice Address - Country:US
Practice Address - Phone:302-644-2773
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2020-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DELG0000345363LF0000X
DEL8-0000127363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
014646C22Medicare PIN
DE020595V39Medicare PIN