Provider Demographics
NPI:1790905941
Name:MARTIN, IRENE (CFNP)
Entity Type:Individual
Prefix:
First Name:IRENE
Middle Name:
Last Name:MARTIN
Suffix:
Gender:F
Credentials:CFNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1014 CAUSEY ROAD
Mailing Address - Street 2:
Mailing Address - City:MCCOMB
Mailing Address - State:MS
Mailing Address - Zip Code:39648
Mailing Address - Country:US
Mailing Address - Phone:601-876-4926
Mailing Address - Fax:601-876-0980
Practice Address - Street 1:120 5TH AVENUE
Practice Address - Street 2:
Practice Address - City:MCCOMB
Practice Address - State:MS
Practice Address - Zip Code:39648
Practice Address - Country:US
Practice Address - Phone:601-249-0013
Practice Address - Fax:601-249-0592
Is Sole Proprietor?:No
Enumeration Date:2007-04-30
Last Update Date:2012-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR736598363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS0111641Medicaid
MSS21404Medicare UPIN
MS0111641Medicaid