Healthcare Provider Details

I. General information

NPI: 1457285074
Provider Name (Legal Business Name): RAEANNA MARTIN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/09/2026
Last Update Date: 06/09/2026
Certification Date: 06/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

56299 29 PALMS HWY
YUCCA VALLEY CA
92284-2857
US

IV. Provider business mailing address

61641 ADOBE DR
JOSHUA TREE CA
92252-2712
US

V. Phone/Fax

Practice location:
  • Phone: 360-722-0792
  • Fax:
Mailing address:
  • Phone: 360-722-0792
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number48992
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: