Provider Demographics
NPI:1598134298
Name:BOOTH, MARTHA JANE
Entity Type:Individual
Prefix:
First Name:MARTHA
Middle Name:JANE
Last Name:BOOTH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 980645
Mailing Address - Street 2:1200 EAST BROAD STREET
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23298-0645
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1200 EAST BROAD STREET
Practice Address - Street 2:WEST HOSPTIAL, 15TH FLOOR, WEST WING
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23298-0645
Practice Address - Country:US
Practice Address - Phone:804-628-3215
Practice Address - Fax:804-827-1016
Is Sole Proprietor?:No
Enumeration Date:2015-09-23
Last Update Date:2015-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024172911363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care