Provider Demographics
NPI:1598736688
Name:MARTINIE, MARY ALICE MC FAD (RN FA)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:ALICE MC FAD
Last Name:MARTINIE
Suffix:
Gender:F
Credentials:RN FA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12670 CREEKSIDE LANE
Mailing Address - Street 2:STE 202
Mailing Address - City:FT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33919-8759
Mailing Address - Country:US
Mailing Address - Phone:239-482-2663
Mailing Address - Fax:239-482-3106
Practice Address - Street 1:12670 CREEKSIDE LANE
Practice Address - Street 2:STE 202
Practice Address - City:FT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33919-8759
Practice Address - Country:US
Practice Address - Phone:239-482-2663
Practice Address - Fax:239-482-3106
Is Sole Proprietor?:No
Enumeration Date:2006-01-28
Last Update Date:2007-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRN1536802163WX0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WX0800XNursing Service ProvidersRegistered NurseOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLY5724ZMedicare ID - Type Unspecified