Healthcare Provider Details

I. General information

NPI: 1629543640
Provider Name (Legal Business Name): JEANNETT MARTINEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/05/2018
Last Update Date: 07/27/2021
Certification Date: 07/27/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

123 GIRARD BLVD SE
ALBUQUERQUE NM
87106-2227
US

IV. Provider business mailing address

123 GIRARD BLVD SE
ALBUQUERQUE NM
87106-2227
US

V. Phone/Fax

Practice location:
  • Phone: 505-726-4407
  • Fax: 505-557-1941
Mailing address:
  • Phone: 505-264-9454
  • Fax: 505-557-1941

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberCNP-54246
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: