Provider Demographics
NPI:1770566689
Name:O'BRIEN, MARTHA BURKE (APRN)
Entity type:Individual
Prefix:MS
First Name:MARTHA
Middle Name:BURKE
Last Name:O'BRIEN
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 1:36 FOLLY BROOK LN
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:CT
Mailing Address - Zip Code:06040-7079
Mailing Address - Country:US
Mailing Address - Phone:860-944-4366
Mailing Address - Fax:
Practice Address - Street 1:1290 SILAS DEANE HWY
Practice Address - Street 2:
Practice Address - City:WETHERSFIELD
Practice Address - State:CT
Practice Address - Zip Code:06109-4337
Practice Address - Country:US
Practice Address - Phone:860-944-4366
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-23
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CTE52807163W00000X
CT001039363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
MB0436748OtherDEA