Healthcare Provider Details

I. General information

NPI: 1023614427
Provider Name (Legal Business Name): MARTHA CLEMENTINA VELASQUEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/10/2020
Last Update Date: 12/10/2020
Certification Date: 12/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2187 S MILITARY TRL
WEST PALM BEACH FL
33415-6453
US

IV. Provider business mailing address

3708 LAURETTE LN
LAKE WORTH FL
33461-3449
US

V. Phone/Fax

Practice location:
  • Phone: 561-641-6865
  • Fax:
Mailing address:
  • Phone: 561-568-3772
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183700000X
TaxonomyPharmacy Technician
License NumberRPT91036
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: