Provider Demographics
NPI:1679521520
Name:MARTIN, MICHELLE RENEE (PNP)
Entity Type:Individual
Prefix:MS
First Name:MICHELLE
Middle Name:RENEE
Last Name:MARTIN
Suffix:
Gender:F
Credentials:PNP
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Mailing Address - Street 1:PO BOX 505402
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63150-5402
Mailing Address - Country:US
Mailing Address - Phone:314-454-5500
Mailing Address - Fax:314-454-5501
Practice Address - Street 1:13001 N OUTER 40 RD
Practice Address - Street 2:STE 330
Practice Address - City:CHESTERFIELD
Practice Address - State:MO
Practice Address - Zip Code:63017-5941
Practice Address - Country:US
Practice Address - Phone:314-454-5500
Practice Address - Fax:314-454-5501
Is Sole Proprietor?:No
Enumeration Date:2006-05-04
Last Update Date:2024-05-09
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MO2019012307363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO428968507Medicaid
MO428968507Medicaid
P88073Medicare UPIN