Healthcare Provider Details

I. General information

NPI: 1134043862
Provider Name (Legal Business Name): WANNAPA MARTINEZ CAMTC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/06/2026
Last Update Date: 08/06/2026
Certification Date: 08/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 LANE AVE STE 128
CHULA VISTA CA
91914-4514
US

IV. Provider business mailing address

2303 CABO BAHIA
CHULA VISTA CA
91914-2039
US

V. Phone/Fax

Practice location:
  • Phone: 619-304-5040
  • Fax:
Mailing address:
  • Phone: 619-948-2465
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number62829
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: