Healthcare Provider Details

I. General information

NPI: 1275495681
Provider Name (Legal Business Name): KATHALEEN VANESSA MARTINEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/25/2025
Last Update Date: 11/25/2025
Certification Date: 11/25/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

330 MOSS ST
CHULA VISTA CA
91911-2005
US

IV. Provider business mailing address

26920 MARLYCE LN
HEMET CA
92543-7260
US

V. Phone/Fax

Practice location:
  • Phone: 619-585-4221
  • Fax:
Mailing address:
  • Phone: 619-602-5410
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number95419375
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: