Healthcare Provider Details

I. General information

NPI: 1790917862
Provider Name (Legal Business Name): TERRY MARTINS RN-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/21/2009
Last Update Date: 08/21/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6218 S 7TH ST
PHOENIX AZ
85042-4211
US

IV. Provider business mailing address

6218 S. 7TH STREET
PHOENIX AZ
85042
US

V. Phone/Fax

Practice location:
  • Phone: 602-304-3117
  • Fax:
Mailing address:
  • Phone: 602-304-3117
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN153728
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: