Provider Demographics
NPI:1538505318
Name:MARTINA, AMY (NP)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:
Last Name:MARTINA
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:AMY
Other - Middle Name:
Other - Last Name:JACKSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:38935 ANN ARBOR RD
Mailing Address - Street 2:CREDENTIALING DEPT
Mailing Address - City:LIVONIA
Mailing Address - State:MI
Mailing Address - Zip Code:48150-3397
Mailing Address - Country:US
Mailing Address - Phone:734-632-0175
Mailing Address - Fax:734-632-0182
Practice Address - Street 1:10000 TELEGRAPH RD
Practice Address - Street 2:
Practice Address - City:TAYLOR
Practice Address - State:MI
Practice Address - Zip Code:48180-3330
Practice Address - Country:US
Practice Address - Phone:313-295-5007
Practice Address - Fax:313-295-6725
Is Sole Proprietor?:No
Enumeration Date:2013-05-20
Last Update Date:2021-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704191045363LA2200X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI12553400OtherCAQH