Provider Demographics
NPI:1477863082
Name:MARTIN, MARY KATHLEEN (ANP)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:KATHLEEN
Last Name:MARTIN
Suffix:
Gender:F
Credentials:ANP
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:KATHLEEN
Other - Last Name:BERRY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:21 W 2ND ST
Mailing Address - Street 2:STE 11
Mailing Address - City:RIVERHEAD
Mailing Address - State:NY
Mailing Address - Zip Code:11901-2752
Mailing Address - Country:US
Mailing Address - Phone:631-722-4400
Mailing Address - Fax:631-722-4426
Practice Address - Street 1:31 MAIN RD
Practice Address - Street 2:
Practice Address - City:RIVERHEAD
Practice Address - State:NY
Practice Address - Zip Code:11901-1953
Practice Address - Country:US
Practice Address - Phone:631-722-4400
Practice Address - Fax:631-722-4426
Is Sole Proprietor?:No
Enumeration Date:2010-10-15
Last Update Date:2017-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF305471363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health