Provider Demographics
NPI:1407209075
Name:MARTIN, MIRENDA (APRN)
Entity Type:Individual
Prefix:
First Name:MIRENDA
Middle Name:
Last Name:MARTIN
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 189
Mailing Address - Street 2:PO BOX 189
Mailing Address - City:SALEM
Mailing Address - State:AR
Mailing Address - Zip Code:72576-0189
Mailing Address - Country:US
Mailing Address - Phone:870-895-2541
Mailing Address - Fax:
Practice Address - Street 1:507 N MAIN STREET
Practice Address - Street 2:SALEM FAMILY CLINIC 507 N MAIN STREET
Practice Address - City:SALEM
Practice Address - State:AR
Practice Address - Zip Code:72576
Practice Address - Country:US
Practice Address - Phone:870-895-2541
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-19
Last Update Date:2016-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARA004739364SF0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SF0001XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistFamily Health