Provider Demographics
NPI:1376159327
Name:MARTIN, CHARITY JAN (FNP-BC)
Entity Type:Individual
Prefix:
First Name:CHARITY
Middle Name:JAN
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 1:507 ELLIS AVE
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:TX
Mailing Address - Zip Code:76579-2515
Mailing Address - Country:US
Mailing Address - Phone:254-913-7475
Mailing Address - Fax:
Practice Address - Street 1:6363 N STATE HIGHWAY 161 STE 100
Practice Address - Street 2:
Practice Address - City:IRVING
Practice Address - State:TX
Practice Address - Zip Code:75038-2239
Practice Address - Country:US
Practice Address - Phone:469-200-3272
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-16
Last Update Date:2022-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1009653207Q00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine