Provider Demographics
NPI:1508448820
Name:IRELAND, MARTHA H (PHD, RN, CS, CEDS)
Entity Type:Individual
Prefix:
First Name:MARTHA
Middle Name:H
Last Name:IRELAND
Suffix:
Gender:F
Credentials:PHD, RN, CS, CEDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23077 CHARMAY POND PL
Mailing Address - Street 2:
Mailing Address - City:BRAMBLETON
Mailing Address - State:VA
Mailing Address - Zip Code:20148-7241
Mailing Address - Country:US
Mailing Address - Phone:703-722-2324
Mailing Address - Fax:
Practice Address - Street 1:23077 CHARMAY POND PL
Practice Address - Street 2:
Practice Address - City:BRAMBLETON
Practice Address - State:VA
Practice Address - Zip Code:20148-7241
Practice Address - Country:US
Practice Address - Phone:703-722-2324
Practice Address - Fax:703-327-6933
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-26
Last Update Date:2021-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCRN1018651364SP0808X
NJ29NJ00296400364SP0808X
DELE0000104364SP0808X
MDAC000754364SP0808X
CA1954364SP0808X
FL94537364SP0808X
VA0015000530364SP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SP0808XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
1891904900OtherNOT A PROVIDER FOR MEDICARE