Provider Demographics
NPI:1790897130
Name:MARTIN, PAULA B (CNS)
Entity Type:Individual
Prefix:MS
First Name:PAULA
Middle Name:B
Last Name:MARTIN
Suffix:
Gender:F
Credentials:CNS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8745 LITZSINGER DR
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63144-2305
Mailing Address - Country:US
Mailing Address - Phone:314-288-9720
Mailing Address - Fax:314-961-4375
Practice Address - Street 1:8745 LITZSINGER DR
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63144-2305
Practice Address - Country:US
Practice Address - Phone:314-288-9720
Practice Address - Fax:314-961-4375
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2009-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO062550363L00000X
IL041-318181363L00000X
MO62550364SP0809X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SP0809XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health, Adult
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
S63746Medicare UPIN