Provider Demographics
NPI:1770130122
Name:MARTIN, AMY MARIE (PMHNP-BC)
Entity type:Individual
Prefix:MRS
First Name:AMY
Middle Name:MARIE
Last Name:MARTIN
Suffix:
Gender:F
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 776347
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-6347
Mailing Address - Country:US
Mailing Address - Phone:502-588-9490
Mailing Address - Fax:502-272-5339
Practice Address - Street 1:1802 E 10TH ST
Practice Address - Street 2:
Practice Address - City:JEFFERSONVILLE
Practice Address - State:IN
Practice Address - Zip Code:47130-6016
Practice Address - Country:US
Practice Address - Phone:812-288-2488
Practice Address - Fax:812-288-6603
Is Sole Proprietor?:No
Enumeration Date:2019-08-21
Last Update Date:2024-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71011592A363LP0808X
KY3013704363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
ININ3604072OtherMEDICARE
IN300061493Medicaid
KY7100619340Medicaid