Healthcare Provider Details

I. General information

NPI: 1154965283
Provider Name (Legal Business Name): COELISE H MARTIN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/31/2019
Last Update Date: 10/31/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

390 40TH ST
OAKLAND CA
94609-2633
US

IV. Provider business mailing address

390 40TH ST
OAKLAND CA
94609-2633
US

V. Phone/Fax

Practice location:
  • Phone: 510-613-0330
  • Fax: 510-569-4589
Mailing address:
  • Phone: 510-613-0330
  • Fax: 510-569-4589

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0807X
TaxonomyChild & Adolescent Psychiatric/Mental Health Registered Nurse
License NumberN9378568
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: