Healthcare Provider Details

I. General information

NPI: 1255776894
Provider Name (Legal Business Name): MARTHA JEAN SUAREZ PMHNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MARTHA JEAN VOLODKEVICH PMHNP

II. Dates (important events)

Enumeration Date: 05/09/2013
Last Update Date: 05/27/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 MERCY CIRCLE
CAMP PENDLETON CA
92055
US

IV. Provider business mailing address

510 1ST AVE SUITE 404
SAN DIEGO CA
92101-6777
US

V. Phone/Fax

Practice location:
  • Phone: 760-725-1555
  • Fax:
Mailing address:
  • Phone: 619-962-8383
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number340032
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number22004
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: