Provider Demographics
NPI:1619127040
Name:SLATTERY, MARTHA P (NP)
Entity Type:Individual
Prefix:MRS
First Name:MARTHA
Middle Name:P
Last Name:SLATTERY
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:650 CENTRE ST
Mailing Address - Street 2:SUITE 102W
Mailing Address - City:BROCKTON
Mailing Address - State:MA
Mailing Address - Zip Code:02302-3308
Mailing Address - Country:US
Mailing Address - Phone:508-580-8682
Mailing Address - Fax:508-583-2515
Practice Address - Street 1:650 CENTRE ST
Practice Address - Street 2:SUITE 102W
Practice Address - City:BROCKTON
Practice Address - State:MA
Practice Address - Zip Code:02302-3308
Practice Address - Country:US
Practice Address - Phone:508-580-8682
Practice Address - Fax:508-583-2515
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-23
Last Update Date:2018-03-28
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MA103002363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110085882AMedicaid
MAP13642Medicare UPIN