Healthcare Provider Details

I. General information

NPI: 1306359294
Provider Name (Legal Business Name): ETHEL DE JESUS MARTINEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/14/2017
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8902 WOODMAN AVE
ARLETA CA
91331-6401
US

IV. Provider business mailing address

8902 WOODMAN AVE
ARLETA CA
91331-6401
US

V. Phone/Fax

Practice location:
  • Phone: 818-830-7133
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95008170
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: