Provider Demographics
NPI:1518307487
Name:MARTIN, KATHLEEN (CNP)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:
Last Name:MARTIN
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:KATHLEEN
Other - Middle Name:
Other - Last Name:GRAHAM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:3850 S NATIONAL AVE
Mailing Address - Street 2:SUITE 600
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65807-5287
Mailing Address - Country:US
Mailing Address - Phone:417-882-4880
Mailing Address - Fax:417-882-7843
Practice Address - Street 1:3850 S NATIONAL AVE
Practice Address - Street 2:SUITE 600
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65807-5287
Practice Address - Country:US
Practice Address - Phone:417-882-4880
Practice Address - Fax:417-882-7843
Is Sole Proprietor?:No
Enumeration Date:2013-06-25
Last Update Date:2020-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2013019751363LF0000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily