Provider Demographics
NPI:1386643401
Name:MARTIN, JENNIFER NICOLE (MSN, ARNP)
Entity type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:NICOLE
Last Name:MARTIN
Suffix:
Gender:F
Credentials:MSN, ARNP
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:NICOLE
Other - Last Name:MYERS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MSN, ARNP
Mailing Address - Street 1:700 E MOUNTAIN VIEW AVE
Mailing Address - Street 2:
Mailing Address - City:ELLENSBURG
Mailing Address - State:WA
Mailing Address - Zip Code:98926-4802
Mailing Address - Country:US
Mailing Address - Phone:509-426-3750
Mailing Address - Fax:509-426-3760
Practice Address - Street 1:700 E MOUNTAIN VIEW AVE STE 505
Practice Address - Street 2:
Practice Address - City:ELLENSBURG
Practice Address - State:WA
Practice Address - Zip Code:98926-4802
Practice Address - Country:US
Practice Address - Phone:509-426-3750
Practice Address - Fax:509-426-3760
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-20
Last Update Date:2024-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP61005937363LX0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LX0001XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL305957000Medicaid
Q06954Medicare UPIN
FLYO43XWMedicare PIN
FLYO43XXMedicare PIN