Healthcare Provider Details

I. General information

NPI: 1235461658
Provider Name (Legal Business Name): ANGELA CHRISTINE MARTINEZ NP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/10/2010
Last Update Date: 03/26/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17561 HIGHWAY B
BOONVILLE MO
65340
US

IV. Provider business mailing address

17651 HIGHWAY B
BOONVILLE MO
65233-2839
US

V. Phone/Fax

Practice location:
  • Phone: 660-882-4140
  • Fax:
Mailing address:
  • Phone: 660-882-4140
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number2010004413
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number2010004413
License Number StateMO
# 3
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number20100004413
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: