Provider Demographics
NPI:1346250123
Name:MARTIN, KATHLEEN E
Entity Type:Individual
Prefix:MS
First Name:KATHLEEN
Middle Name:E
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 1:931 SOUTHVIEW DR
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VT
Mailing Address - Zip Code:05477-9066
Mailing Address - Country:US
Mailing Address - Phone:802-578-2786
Mailing Address - Fax:
Practice Address - Street 1:790 COLLEGE PKWY
Practice Address - Street 2:
Practice Address - City:COLCHESTER
Practice Address - State:VT
Practice Address - Zip Code:05446-3007
Practice Address - Country:US
Practice Address - Phone:802-847-1170
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT1010023400363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
VTONP1066Medicaid
VTONP1066Medicaid
VTMANP1066Medicare ID - Type Unspecified