Healthcare Provider Details

I. General information

NPI: 1053972158
Provider Name (Legal Business Name): KORI DAWN MARTINEZ APRN-FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/28/2019
Last Update Date: 06/28/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2301 YALE BLVD SE STE D3
ALBUQUERQUE NM
87106-4355
US

IV. Provider business mailing address

2301 YALE BLVD SE STE D3
ALBUQUERQUE NM
87106-4355
US

V. Phone/Fax

Practice location:
  • Phone: 505-842-4433
  • Fax: 505-842-4436
Mailing address:
  • Phone: 505-842-4433
  • Fax: 505-842-4436

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number56734
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: