Provider Demographics
NPI:1629663141
Name:BARCK, MARTHA (CNP)
Entity Type:Individual
Prefix:
First Name:MARTHA
Middle Name:
Last Name:BARCK
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:MARTHA
Other - Middle Name:
Other - Last Name:DOMPIERRE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:570 PROFESSIONAL DR
Mailing Address - Street 2:
Mailing Address - City:NORTHFIELD
Mailing Address - State:MN
Mailing Address - Zip Code:55057-2756
Mailing Address - Country:US
Mailing Address - Phone:507-301-3412
Mailing Address - Fax:
Practice Address - Street 1:1400 JEFFERSON RD
Practice Address - Street 2:
Practice Address - City:NORTHFIELD
Practice Address - State:MN
Practice Address - Zip Code:55057-3081
Practice Address - Country:US
Practice Address - Phone:507-663-9000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-05
Last Update Date:2023-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN8059363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health