Provider Demographics
NPI:1821225343
Name:MARTIN, KATHLEEN A (NP)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:A
Last Name:MARTIN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:620 BROAD ST
Mailing Address - Street 2:CENTRAL STATE HOSPITAL
Mailing Address - City:MILLEDGEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31062-7525
Mailing Address - Country:US
Mailing Address - Phone:478-445-4128
Mailing Address - Fax:
Practice Address - Street 1:620 BROAD ST
Practice Address - Street 2:CENTRAL STATE HOSPITAL
Practice Address - City:MILLEDGEVILLE
Practice Address - State:GA
Practice Address - Zip Code:31062-7525
Practice Address - Country:US
Practice Address - Phone:478-445-4128
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-06-11
Last Update Date:2009-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN114158NP363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
GARN114158NPOtherLICENSE NUMBER