Provider Demographics
NPI:1669862348
Name:DEMARTINO, DARRELL (FNP-BC, RN, EMT-P)
Entity Type:Individual
Prefix:
First Name:DARRELL
Middle Name:
Last Name:DEMARTINO
Suffix:
Gender:M
Credentials:FNP-BC, RN, EMT-P
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:206 REDMOND PINES DR
Mailing Address - Street 2:
Mailing Address - City:WENTZVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:63385-4304
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:12303 DEPAUL DRIVE
Practice Address - Street 2:
Practice Address - City:BRIDGETON
Practice Address - State:MO
Practice Address - Zip Code:63044
Practice Address - Country:US
Practice Address - Phone:517-242-1705
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-02-02
Last Update Date:2018-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOP-20168146L00000X
MI3201009993146L00000X
MI4704274228163W00000X, 363LF0000X
MO2016044503163WE0003X
MO2017002498363LF0000X
MO2017002497363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No146L00000XEmergency Medical Service ProvidersEmergency Medical Technician, Paramedic
No163W00000XNursing Service ProvidersRegistered Nurse
No163WE0003XNursing Service ProvidersRegistered NurseEmergency
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily