Provider Demographics
NPI:1609368919
Name:CHARLEY, MARTHA G (FNP)
Entity Type:Individual
Prefix:MRS
First Name:MARTHA
Middle Name:G
Last Name:CHARLEY
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 1:637 WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:DORCHESTER
Mailing Address - State:MA
Mailing Address - Zip Code:02124-3510
Mailing Address - Country:US
Mailing Address - Phone:617-825-9660
Mailing Address - Fax:617-288-7898
Practice Address - Street 1:SOUTHBRIDGE PAIN CLINIC
Practice Address - Street 2:48 MAIN STREET SUITE 6
Practice Address - City:STURBRIDGE
Practice Address - State:MA
Practice Address - Zip Code:01566
Practice Address - Country:US
Practice Address - Phone:508-347-9111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-01
Last Update Date:2023-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIAPRN01800363LF0000X
MARN213217363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110197544AMedicaid