Provider Demographics
NPI:1508652371
Name:MARTIN, KELLY MARIE (NP)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:MARIE
Last Name:MARTIN
Suffix:
Gender:
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:96 CONNER CIR
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32459-5027
Mailing Address - Country:US
Mailing Address - Phone:805-558-1283
Mailing Address - Fax:
Practice Address - Street 1:96 CONNER CIR
Practice Address - Street 2:
Practice Address - City:SANTA ROSA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32459-5027
Practice Address - Country:US
Practice Address - Phone:805-558-1283
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-04-17
Last Update Date:2025-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11038829363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily