Healthcare Provider Details

I. General information

NPI: 1487027272
Provider Name (Legal Business Name): MARTHA MADRID R.N.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MARTHA J MADRID R.N.

II. Dates (important events)

Enumeration Date: 11/03/2015
Last Update Date: 04/05/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2625 E INDIAN SCHOOL RD UNIT 115
PHOENIX AZ
85016-6794
US

IV. Provider business mailing address

2625 E INDIAN SCHOOL RD UNIT 115
PHOENIX AZ
85016-6794
US

V. Phone/Fax

Practice location:
  • Phone: 406-860-8057
  • Fax:
Mailing address:
  • Phone: 406-860-8057
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WD0400X
TaxonomyDiabetes Educator Registered Nurse
License Number25249
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: