Provider Demographics
NPI:1700971231
Name:MARTY, MONIQUE (FNP)
Entity Type:Individual
Prefix:
First Name:MONIQUE
Middle Name:
Last Name:MARTY
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1021 W OAKLAND AVE
Mailing Address - Street 2:SUITE 207
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37604-2191
Mailing Address - Country:US
Mailing Address - Phone:423-916-5106
Mailing Address - Fax:423-952-3109
Practice Address - Street 1:403 N STATE OF FRANKLIN RD
Practice Address - Street 2:
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37604-6034
Practice Address - Country:US
Practice Address - Phone:423-431-7111
Practice Address - Fax:423-431-7092
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2009-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNRN114496363L00000X
TNAPN10995363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
Q49274Medicare UPIN
TN3641157Medicare PIN
TNP00403712Medicare PIN