Provider Demographics
NPI:1255045761
Name:MARTIN, AMY REBECCA (NP)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:REBECCA
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 1:107 GROVEVIEW TRL
Mailing Address - Street 2:
Mailing Address - City:MAULDIN
Mailing Address - State:SC
Mailing Address - Zip Code:29662-3033
Mailing Address - Country:US
Mailing Address - Phone:706-513-0245
Mailing Address - Fax:
Practice Address - Street 1:25 S LAURENS ST
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29601-2716
Practice Address - Country:US
Practice Address - Phone:864-663-1266
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-09
Last Update Date:2023-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC26492363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner