Basic Information
| Provider Information | |||||||||
| NPI: | 1770827503 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BROWN | ||||||||
| FirstName: | MARTHA | ||||||||
| MiddleName: | ELIZABETH | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | FNP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
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| OtherMiddleName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 25 DEPOT ST | ||||||||
| Address2: | |||||||||
| City: | KINGFIELD | ||||||||
| State: | ME | ||||||||
| PostalCode: | 049474208 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2072654555 | ||||||||
| FaxNumber: | 2072645004 | ||||||||
| Practice Location | |||||||||
| Address1: | 25 DEPOT ST | ||||||||
| Address2: | |||||||||
| City: | KINGFIELD | ||||||||
| State: | ME | ||||||||
| PostalCode: | 049474208 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2072654555 | ||||||||
| FaxNumber: | 2072645004 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/16/2012 | ||||||||
| LastUpdateDate: | 07/08/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | 06/07/2022 | ||||||||
| NPIReactivationDate: | 07/08/2022 | ||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 07/08/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | CNP171018 | ME | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LF0000X | ARNP1514222 | FL | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LF0000X | 4704305289 | MI | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LF0000X | 1461 | AK | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LF0000X | CNP-02420 | NM | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LF0000X | AP8534 | AZ | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 0093046000 | 05 | FL | MEDICAID | 26304244 | 05 | NM | MEDICAID | Y0J7W | 01 | FL | FLORIDA BLUE | OTHER |