Provider Demographics
NPI:1992270995
Name:JULIE K MARTIN, PMHNP-BC, LLC
Entity type:Organization
Organization Name:JULIE K MARTIN, PMHNP-BC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/ PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:JULIE
Authorized Official - Middle Name:
Authorized Official - Last Name:MARTIN
Authorized Official - Suffix:
Authorized Official - Credentials:PMHNP-BC
Authorized Official - Phone:228-547-1945
Mailing Address - Street 1:1403 43RD AVE
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39501-2545
Mailing Address - Country:US
Mailing Address - Phone:228-547-1945
Mailing Address - Fax:
Practice Address - Street 1:1403 43RD AVE
Practice Address - Street 2:
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39501-2545
Practice Address - Country:US
Practice Address - Phone:228-861-5240
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-10-05
Last Update Date:2020-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS02372080Medicaid