Provider Demographics
NPI:1174872303
Name:MARTINO, KELLY M (CNM, ARNP)
Entity type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:M
Last Name:MARTINO
Suffix:
Gender:F
Credentials:CNM, ARNP
Other - Prefix:MS
Other - First Name:KELLY
Other - Middle Name:M
Other - Last Name:STANDEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 25608
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84125-0608
Mailing Address - Country:US
Mailing Address - Phone:206-320-4476
Mailing Address - Fax:206-568-7043
Practice Address - Street 1:5350 TALLMAN AVE NW STE 420
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98107-5902
Practice Address - Country:US
Practice Address - Phone:206-781-6080
Practice Address - Fax:206-781-6285
Is Sole Proprietor?:No
Enumeration Date:2012-09-04
Last Update Date:2022-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WARN60863154163W00000X
WAAP60864424367A00000X, 367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1174872303Medicaid
FL006530200Medicaid