Basic Information
| Provider Information | |||||||||
| NPI: | 1497781454 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MARTIN | ||||||||
| FirstName: | DANA | ||||||||
| MiddleName: | KAY | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | C.F.N.P. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | CHURCHWELL | ||||||||
| OtherFirstName: | DANA | ||||||||
| OtherMiddleName: | KAY | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1 PRIME CARE DR | ||||||||
| Address2: | |||||||||
| City: | SELMER | ||||||||
| State: | TN | ||||||||
| PostalCode: | 383751864 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7316457932 | ||||||||
| FaxNumber: | 7316455195 | ||||||||
| Practice Location | |||||||||
| Address1: | 1 PRIME CARE DR | ||||||||
| Address2: | |||||||||
| City: | SELMER | ||||||||
| State: | TN | ||||||||
| PostalCode: | 383751864 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7316457932 | ||||||||
| FaxNumber: | 7316455195 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/23/2006 | ||||||||
| LastUpdateDate: | 10/18/2010 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 111819 | TN | N | Nursing Service Providers | Registered Nurse | 363LF0000X | 7459 | TN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.