Basic Information
| Provider Information | |||||||||
| NPI: | 1003149261 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MARTIN | ||||||||
| FirstName: | KATHY | ||||||||
| MiddleName: | JOAN | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4186 EAST STATE HWY 248 | ||||||||
| Address2: | |||||||||
| City: | REEDS SPRING | ||||||||
| State: | MO | ||||||||
| PostalCode: | 65737 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4172945971 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 4186 EAST STATE HWY 248 | ||||||||
| Address2: | |||||||||
| City: | REEDS SPRING | ||||||||
| State: | MO | ||||||||
| PostalCode: | 65737 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4172945971 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/04/2009 | ||||||||
| LastUpdateDate: | 07/24/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 2005035596 | MO | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.