Provider Demographics
NPI:1467685511
Name:MARTINSEN, MISTY M (FNP, MSN)
Entity Type:Individual
Prefix:MRS
First Name:MISTY
Middle Name:M
Last Name:MARTINSEN
Suffix:
Gender:F
Credentials:FNP, MSN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1951 BENCH RD STE B
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201-2073
Mailing Address - Country:US
Mailing Address - Phone:208-238-1000
Mailing Address - Fax:
Practice Address - Street 1:220 BANNOCK ST
Practice Address - Street 2:
Practice Address - City:MALAD CITY
Practice Address - State:ID
Practice Address - Zip Code:83252-5068
Practice Address - Country:US
Practice Address - Phone:208-766-2600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-08-24
Last Update Date:2023-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDNP-921A363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner