Provider Demographics
NPI:1598821191
Name:MARTIN, MARY ANN (MHNP)
Entity type:Individual
Prefix:MRS
First Name:MARY
Middle Name:ANN
Last Name:MARTIN
Suffix:
Gender:F
Credentials:MHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2901 DUBBERLY CT
Mailing Address - Street 2:
Mailing Address - City:MATTHEWS
Mailing Address - State:NC
Mailing Address - Zip Code:28105-0616
Mailing Address - Country:US
Mailing Address - Phone:704-719-3664
Mailing Address - Fax:704-719-3664
Practice Address - Street 1:839 MAJESTIC CT STE 1
Practice Address - Street 2:
Practice Address - City:GASTONIA
Practice Address - State:NC
Practice Address - Zip Code:28054-5152
Practice Address - Country:US
Practice Address - Phone:704-867-6188
Practice Address - Fax:704-866-6070
Is Sole Proprietor?:No
Enumeration Date:2006-12-28
Last Update Date:2009-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0050-02313363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6113022Medicaid