Provider Demographics
NPI:1508125055
Name:MARTIN, TRACEY (RN)
Entity Type:Individual
Prefix:
First Name:TRACEY
Middle Name:
Last Name:MARTIN
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2104 LEWIS TURNER BLVD
Mailing Address - Street 2:
Mailing Address - City:FORT WALTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32547-1316
Mailing Address - Country:US
Mailing Address - Phone:850-862-3728
Mailing Address - Fax:850-862-6270
Practice Address - Street 1:2104 LEWIS TURNER BLVD
Practice Address - Street 2:
Practice Address - City:FORT WALTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:32547-1316
Practice Address - Country:US
Practice Address - Phone:850-862-3728
Practice Address - Fax:850-862-6270
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-03
Last Update Date:2012-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRN3205862163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163W00000XNursing Service ProvidersRegistered NurseGroup - Multi-Specialty