Provider Demographics
NPI:1629685938
Name:MARTINA, NICOLE (APRN)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:MARTINA
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:205 HOUSE ST
Mailing Address - Street 2:
Mailing Address - City:GLASTONBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06033-1295
Mailing Address - Country:US
Mailing Address - Phone:860-595-7428
Mailing Address - Fax:
Practice Address - Street 1:80 SEYMOUR ST
Practice Address - Street 2:
Practice Address - City:HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06106-3315
Practice Address - Country:US
Practice Address - Phone:860-545-2000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-30
Last Update Date:2020-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT7958363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty