Provider Demographics
NPI:1205902624
Name:MARTIN, MARY ELIZABETH (RN)
Entity type:Individual
Prefix:MRS
First Name:MARY
Middle Name:ELIZABETH
Last Name:MARTIN
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:463 SCOTT RD
Mailing Address - Street 2:
Mailing Address - City:SANDY CREEK
Mailing Address - State:NY
Mailing Address - Zip Code:13145-2154
Mailing Address - Country:US
Mailing Address - Phone:315-387-6683
Mailing Address - Fax:
Practice Address - Street 1:595 W MAIN ST
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:NY
Practice Address - Zip Code:13601-1335
Practice Address - Country:US
Practice Address - Phone:315-888-2228
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-28
Last Update Date:2023-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY260901164W00000X
NY843451163WA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WA0400XNursing Service ProvidersRegistered NurseAddiction (Substance Use Disorder)
No164W00000XNursing Service ProvidersLicensed Practical Nurse