Provider Demographics
NPI:1942454608
Name:MARTIN, MICHELLE RENAE (NP)
Entity Type:Individual
Prefix:MRS
First Name:MICHELLE
Middle Name:RENAE
Last Name:MARTIN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:RENAE
Other - Last Name:MARTIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:9119 W 74TH ST STE 260
Mailing Address - Street 2:
Mailing Address - City:MERRIAM
Mailing Address - State:KS
Mailing Address - Zip Code:66204-2268
Mailing Address - Country:US
Mailing Address - Phone:913-632-9480
Mailing Address - Fax:913-632-9499
Practice Address - Street 1:9119 W 74TH ST STE 260
Practice Address - Street 2:
Practice Address - City:MERRIAM
Practice Address - State:KS
Practice Address - Zip Code:66204-2268
Practice Address - Country:US
Practice Address - Phone:913-632-9480
Practice Address - Fax:913-632-9499
Is Sole Proprietor?:No
Enumeration Date:2008-11-07
Last Update Date:2017-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2004027607363LA2200X
KS5375286363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health