Provider Demographics
NPI:1447244504
Name:MARTIN, AMY G (APRN)
Entity type:Individual
Prefix:MRS
First Name:AMY
Middle Name:G
Last Name:MARTIN
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:345 MONTAUK AVE
Mailing Address - Street 2:
Mailing Address - City:NEW LONDON
Mailing Address - State:CT
Mailing Address - Zip Code:06320-4738
Mailing Address - Country:US
Mailing Address - Phone:860-444-6868
Mailing Address - Fax:860-437-0650
Practice Address - Street 1:345 MONTAUK AVE
Practice Address - Street 2:
Practice Address - City:NEW LONDON
Practice Address - State:CT
Practice Address - Zip Code:06320-4738
Practice Address - Country:US
Practice Address - Phone:860-444-6868
Practice Address - Fax:860-437-0650
Is Sole Proprietor?:No
Enumeration Date:2005-09-06
Last Update Date:2014-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001886363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT101886OtherCONNECTICARE
CT004197027Medicaid
CT2V5539OtherHEALTH NET
CT101886OtherCONNECTICARE
CT004197027Medicaid