Provider Demographics
NPI:1578550935
Name:MARTIN, MARYANN (NP)
Entity Type:Individual
Prefix:
First Name:MARYANN
Middle Name:
Last Name:MARTIN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1051 PORT MALABAR BLVD NE
Mailing Address - Street 2:SUITE 6, PORT MALABAR PROFESSIONAL BLDG
Mailing Address - City:PALM BAY
Mailing Address - State:FL
Mailing Address - Zip Code:32905-5153
Mailing Address - Country:US
Mailing Address - Phone:321-727-9063
Mailing Address - Fax:
Practice Address - Street 1:1051 PORT MALABAR BLVD NE
Practice Address - Street 2:SUITE 6, PORT MALABAR PROFESSIONAL BLDG
Practice Address - City:PALM BAY
Practice Address - State:FL
Practice Address - Zip Code:32905-5153
Practice Address - Country:US
Practice Address - Phone:321-727-9063
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP9168017363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
Q44129Medicare UPIN
FLU4811ZMedicare ID - Type Unspecified