Healthcare Provider Details

I. General information

NPI: 1174520480
Provider Name (Legal Business Name): BONNIE JANE MARTIN FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/30/2005
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7373 WEST LN
STOCKTON CA
95210-3377
US

IV. Provider business mailing address

7373 WEST LN
STOCKTON CA
95210-3377
US

V. Phone/Fax

Practice location:
  • Phone: 209-476-3928
  • Fax: 209-476-3675
Mailing address:
  • Phone: 209-476-3928
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN230731
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: