Healthcare Provider Details

I. General information

NPI: 1891478442
Provider Name (Legal Business Name): MARIA SALOME MATHEWS MARTIN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/10/2023
Last Update Date: 08/10/2023
Certification Date: 08/08/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25825 VERMONT AVE, LOS ANGELES, CA 90710
LOS ANGELES CA
90710
US

IV. Provider business mailing address

6507 OCEAN CREST DR APT 309
RANCHO PALOS VERDES CA
90275-5442
US

V. Phone/Fax

Practice location:
  • Phone: 833-574-2273
  • Fax:
Mailing address:
  • Phone: 410-897-7816
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95025856
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code163WX0003X
TaxonomyInpatient Obstetric Registered Nurse
License Number95207026
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: