Basic Information
| Provider Information | |||||||||
| NPI: | 1790071413 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MARTIN | ||||||||
| FirstName: | KENYA | ||||||||
| MiddleName: | N | ||||||||
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| Credential: | CRNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2804 SOUTHAMPTON RD | ||||||||
| Address2: | CONCENTRA | ||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191541207 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2156770930 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2804 SOUTHAMPTON RD | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191541207 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2156770930 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/21/2011 | ||||||||
| LastUpdateDate: | 01/20/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | SP011228 | PA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.