Provider Demographics
NPI:1942267703
Name:MARTIN, MILDRED LOUISE (RN,MSN,MA,PMHNP-BC)
Entity Type:Individual
Prefix:
First Name:MILDRED
Middle Name:LOUISE
Last Name:MARTIN
Suffix:
Gender:F
Credentials:RN,MSN,MA,PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:164 WACCAMAW MEDICAL PARK DR
Mailing Address - Street 2:
Mailing Address - City:CONWAY
Mailing Address - State:SC
Mailing Address - Zip Code:29526-8903
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:164 WACCAMAW MEDICAL PARK DR
Practice Address - Street 2:
Practice Address - City:CONROY
Practice Address - State:SC
Practice Address - Zip Code:29526
Practice Address - Country:US
Practice Address - Phone:843-347-4888
Practice Address - Fax:843-347-4102
Is Sole Proprietor?:No
Enumeration Date:2006-04-27
Last Update Date:2014-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV000720363LP0808X
SC17888APRN363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC327877Medicaid
SC327877Medicaid