Healthcare Provider Details

I. General information

NPI: 1174889562
Provider Name (Legal Business Name): LETICIA YVONNE BRAZIL MILITARY PROVIDER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LETICIA YVONNE MARTIN PARAMEDIC

II. Dates (important events)

Enumeration Date: 04/10/2012
Last Update Date: 02/17/2022
Certification Date: 02/17/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

331 SIJAN AVE.
WHITEMAN AFB MO
65305-5001
US

IV. Provider business mailing address

207 SW T HWY
KINGSVILLE MO
64061-9229
US

V. Phone/Fax

Practice location:
  • Phone: 940-704-8099
  • Fax:
Mailing address:
  • Phone: 940-704-8099
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code146L00000X
TaxonomyParamedic
License NumberM5025933
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code1710I1003X
TaxonomyIndependent Duty Medical Technicians
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: