Healthcare Provider Details

I. General information

NPI: 1417592437
Provider Name (Legal Business Name): HEIDI EDITH MARTINEZ MARQUEZ RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/13/2019
Last Update Date: 11/13/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1817 N 7TH ST
PHOENIX AZ
85006-2133
US

IV. Provider business mailing address

5420 N 63RD DR
GLENDALE AZ
85301-6502
US

V. Phone/Fax

Practice location:
  • Phone: 602-257-3904
  • Fax:
Mailing address:
  • Phone: 623-383-0482
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN215884
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: