Provider Demographics
NPI:1154560852
Name:MARTIN, MICAELLE (NP)
Entity type:Individual
Prefix:MRS
First Name:MICAELLE
Middle Name:
Last Name:MARTIN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:36 GARDNER ST
Mailing Address - Street 2:
Mailing Address - City:EAST WINDSOR
Mailing Address - State:CT
Mailing Address - Zip Code:06088-9675
Mailing Address - Country:US
Mailing Address - Phone:860-292-4000
Mailing Address - Fax:860-292-8326
Practice Address - Street 1:36 GARDNER ST
Practice Address - Street 2:
Practice Address - City:EAST WINDSOR
Practice Address - State:CT
Practice Address - Zip Code:06088-9675
Practice Address - Country:US
Practice Address - Phone:860-292-4000
Practice Address - Fax:860-292-8326
Is Sole Proprietor?:No
Enumeration Date:2009-02-19
Last Update Date:2015-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA195552363L00000X
CT006123363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics