Provider Demographics
NPI:1790152973
Name:MARTIN, KRISTY (FNP-BC)
Entity Type:Individual
Prefix:
First Name:KRISTY
Middle Name:
Last Name:MARTIN
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1758 S LAURELHURST DR
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84108-3310
Mailing Address - Country:US
Mailing Address - Phone:978-457-5992
Mailing Address - Fax:
Practice Address - Street 1:2750 S 5600 W
Practice Address - Street 2:
Practice Address - City:WEST VALLEY CITY
Practice Address - State:UT
Practice Address - Zip Code:84120-1249
Practice Address - Country:US
Practice Address - Phone:801-417-5732
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-24
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT9484112-4405363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily