Provider Demographics
NPI:1518721117
Name:MARTIN, KATHY DORIS (ACNPC-AG)
Entity Type:Individual
Prefix:MISS
First Name:KATHY
Middle Name:DORIS
Last Name:MARTIN
Suffix:
Gender:F
Credentials:ACNPC-AG
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:450 TOWN FARM RD
Mailing Address - Street 2:
Mailing Address - City:PASCOAG
Mailing Address - State:RI
Mailing Address - Zip Code:02859-2419
Mailing Address - Country:US
Mailing Address - Phone:401-767-6310
Mailing Address - Fax:
Practice Address - Street 1:450 TOWN FARM RD
Practice Address - Street 2:
Practice Address - City:PASCOAG
Practice Address - State:RI
Practice Address - Zip Code:02859-2419
Practice Address - Country:US
Practice Address - Phone:401-767-6310
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-13
Last Update Date:2024-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RI230006363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner