Healthcare Provider Details

I. General information

NPI: 1588814263
Provider Name (Legal Business Name): FONSHAY LATRICE MARTIN GNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/30/2008
Last Update Date: 10/02/2024
Certification Date: 10/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

999 18TH ST STE 3000
DENVER CO
80202-2449
US

IV. Provider business mailing address

15333 N PIMA RD STE 305
SCOTTSDALE AZ
85260-2717
US

V. Phone/Fax

Practice location:
  • Phone: 888-731-8994
  • Fax:
Mailing address:
  • Phone: 888-731-8994
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number705048
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number860200
License Number StateNV
# 3
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License NumberAP115919
License Number StateTX
# 4
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number70334
License Number StateNM
# 5
Primary TaxonomyY
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number5381716052
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: