Provider Demographics
NPI:1972284131
Name:MARTH, KRISTIN NICHOLE
Entity Type:Individual
Prefix:
First Name:KRISTIN
Middle Name:NICHOLE
Last Name:MARTH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3222 W BAJADA DR
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85083-5823
Mailing Address - Country:US
Mailing Address - Phone:623-205-6473
Mailing Address - Fax:
Practice Address - Street 1:9171 W THUNDERBIRD RD STE 101
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:AZ
Practice Address - Zip Code:85381-4872
Practice Address - Country:US
Practice Address - Phone:623-877-0100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-28
Last Update Date:2023-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ295338363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily