1609275049 NPI number — MRS. NICKI DAWN MARTIN APRN,FNP-BC

Table of content: MRS. NICKI DAWN MARTIN APRN,FNP-BC (NPI 1609275049)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1609275049 NPI number — MRS. NICKI DAWN MARTIN APRN,FNP-BC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MARTIN
Provider First Name:
NICKI
Provider Middle Name:
DAWN
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
APRN,FNP-BC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
KIRBY
Provider Other First Name:
NICKI
Provider Other Middle Name:
DAWN
Provider Other Name Prefix Text:
MRS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
APRN,FNP-BC
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1609275049
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/01/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
186 ELDER AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PRINCETON
Provider Business Mailing Address State Name:
WV
Provider Business Mailing Address Postal Code:
24739
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
762-340-9353
Provider Business Mailing Address Fax Number:
404-645-7572

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
MED EXPRESS
Provider Second Line Business Practice Location Address:
277 GREASY RIDGE RD
Provider Business Practice Location Address City Name:
PRINCETON
Provider Business Practice Location Address State Name:
WV
Provider Business Practice Location Address Postal Code:
24740
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
304-425-7615
Provider Business Practice Location Address Fax Number:
304-425-7635
Provider Enumeration Date:
08/21/2014

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363L00000X , with the licence number:  APRN68714-FNP-BC , registered in the state of WV ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LF0000X , with the licence number: APRN68714-FNP-BC , registered in the state of WV ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 363LF0000X , with the licence number: 0024172549 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 3810028855 , issued by the state of ( WV ) . This identifiers is of the category "MEDICAID".