Healthcare Provider Details

I. General information

NPI: 1962336735
Provider Name (Legal Business Name): KIERIANNA MARTINEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/09/2026
Last Update Date: 07/17/2026
Certification Date: 07/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2667 E GALA CT STE 110
MERIDIAN ID
83642-2791
US

IV. Provider business mailing address

2667 E GALA CT STE 110
MERIDIAN ID
83642-2791
US

V. Phone/Fax

Practice location:
  • Phone: 208-944-2354
  • Fax:
Mailing address:
  • Phone: 208-944-2354
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberF06260308
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: