Healthcare Provider Details

I. General information

NPI: 1609101997
Provider Name (Legal Business Name): CAROLYN MOSS MARTINEZ FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/05/2009
Last Update Date: 06/12/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1016 OUTER RD
SAN DIEGO CA
92154
US

IV. Provider business mailing address

PO BOX 459
IMPERIAL BEACH CA
91933-0459
US

V. Phone/Fax

Practice location:
  • Phone: 619-429-3733
  • Fax:
Mailing address:
  • Phone: 619-429-3733
  • Fax: 619-429-3733

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number22031
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: