Healthcare Provider Details

I. General information

NPI: 1578093316
Provider Name (Legal Business Name): AMALIA LISA MARTINEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/14/2017
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7515 VAN NUYS BLVD
VAN NUYS CA
91405-1949
US

IV. Provider business mailing address

7515 VAN NUYS BLVD
VAN NUYS CA
91405-1949
US

V. Phone/Fax

Practice location:
  • Phone: 818-627-3050
  • Fax: 818-627-3052
Mailing address:
  • Phone: 818-627-3050
  • Fax: 818-627-3052

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP2201X
TaxonomyAmbulatory Care Registered Nurse
License Number624490
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: