Healthcare Provider Details

I. General information

NPI: 1780504613
Provider Name (Legal Business Name): TABETHA MARTIN RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/20/2026
Last Update Date: 07/20/2026
Certification Date: 07/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12618 SIERRA ROJO RD
VALLEY CENTER CA
92082-5719
US

IV. Provider business mailing address

PO BOX 1922
VALLEY CENTER CA
92082-1922
US

V. Phone/Fax

Practice location:
  • Phone: 760-317-6111
  • Fax:
Mailing address:
  • Phone: 760-317-6111
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number95208086
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code163WC0400X
TaxonomyCase Management Registered Nurse
License Number95208086
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code163WC1500X
TaxonomyCommunity Health Registered Nurse
License Number558692
License Number StateCA
# 4
Primary TaxonomyY
Taxonomy Code163WH0200X
TaxonomyHome Health Registered Nurse
License Number95208086
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: