Provider Demographics
NPI:1578507901
Name:MARTIN, SUSAN KIMBERLY (FNP)
Entity Type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:KIMBERLY
Last Name:MARTIN
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1002 E MCDOWELL RD
Mailing Address - Street 2:SUITE 120
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85006-2625
Mailing Address - Country:US
Mailing Address - Phone:602-256-2273
Mailing Address - Fax:602-258-5638
Practice Address - Street 1:1002 E MCDOWELL RD
Practice Address - Street 2:SUITE 120
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85006-2625
Practice Address - Country:US
Practice Address - Phone:602-256-2273
Practice Address - Fax:602-258-5638
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZFNP AP0555163WP2201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP2201XNursing Service ProvidersRegistered NurseAmbulatory Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ054191Medicaid
AZQ51620Medicare UPIN
AZ105314Medicare ID - Type Unspecified