Healthcare Provider Details

I. General information

NPI: 1407309552
Provider Name (Legal Business Name): MONICA NICOLE MARTIN LICENSED VOCATIONAL
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/25/2016
Last Update Date: 01/31/2023
Certification Date: 01/31/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1670 E 120TH ST
LOS ANGELES CA
90059-3026
US

IV. Provider business mailing address

1670 E 120TH ST
LOS ANGELES CA
90059-3026
US

V. Phone/Fax

Practice location:
  • Phone: 424-463-0054
  • Fax:
Mailing address:
  • Phone: 424-753-9001
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License NumberVN281766
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: