Healthcare Provider Details

I. General information

NPI: 1619423902
Provider Name (Legal Business Name): MISS MARIAH MAUREEN MARTINEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/28/2016
Last Update Date: 04/05/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1421 MONTANA VISTA ST
ESPANOLA NM
87532
US

IV. Provider business mailing address

PO BOX 1141
ESPANOLA NM
87532-1141
US

V. Phone/Fax

Practice location:
  • Phone: 505-929-0123
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number502695304
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: