Healthcare Provider Details

I. General information

NPI: 1538087218
Provider Name (Legal Business Name): STACIE ANN MARTIN APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/09/2026
Last Update Date: 07/09/2026
Certification Date: 07/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

516 W ATEN RD STE 2
IMPERIAL CA
92251-9805
US

IV. Provider business mailing address

6154 CARLING WAY
SAN DIEGO CA
92115-5528
US

V. Phone/Fax

Practice location:
  • Phone: 619-961-8799
  • Fax: 760-355-7731
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number95039923
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: