Healthcare Provider Details

I. General information

NPI: 1013513779
Provider Name (Legal Business Name): MARY KATHLEEN MARTINEZ PMHNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/08/2020
Last Update Date: 06/25/2025
Certification Date: 06/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4425 JUAN TABO BLVD NE STE 112
ALBUQUERQUE NM
87111-2684
US

IV. Provider business mailing address

4425 JUAN TABO BLVD NE
ALBUQUERQUE NM
87111-2681
US

V. Phone/Fax

Practice location:
  • Phone: 505-503-6800
  • Fax: 866-530-1835
Mailing address:
  • Phone: 505-503-6800
  • Fax: 866-530-1835

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberAPRN-62222
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: