Healthcare Provider Details

I. General information

NPI: 1902959364
Provider Name (Legal Business Name): NICOLE MARTINEZKISS PT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/19/2007
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7801 WILSHIRE AVE NE LA CUEVA HS
ALBUQUERQUE NM
87122-2807
US

IV. Provider business mailing address

7801 WILSHIRE AVE NE LA CUEVA HS
ALBUQUERQUE NM
87122-2807
US

V. Phone/Fax

Practice location:
  • Phone: 505-823-2327
  • Fax:
Mailing address:
  • Phone: 505-823-2327
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number2622
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: