Provider Demographics
NPI:1609313311
Name:MARY A MARTIN NP BC
Entity Type:Organization
Organization Name:MARY A MARTIN NP BC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHIATRIC NURSE PRACTITIONER OWNE
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:MARTIN
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:704-200-1122
Mailing Address - Street 1:6809 FAIRVIEW RD
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28210-4195
Mailing Address - Country:US
Mailing Address - Phone:704-200-1122
Mailing Address - Fax:704-464-1781
Practice Address - Street 1:10430 HADDINGTON DR NW
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28269-6955
Practice Address - Country:US
Practice Address - Phone:704-200-1122
Practice Address - Fax:704-464-1781
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-20
Last Update Date:2017-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5002313261QM0850X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health