Healthcare Provider Details

I. General information

NPI: 1104433952
Provider Name (Legal Business Name): JOLI ANN MARTINEZ CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/25/2020
Last Update Date: 09/25/2020
Certification Date: 09/24/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2028 COBA RD SE
RIO RANCHO NM
87124-8913
US

IV. Provider business mailing address

2028 COBA RD SE
RIO RANCHO NM
87124-8913
US

V. Phone/Fax

Practice location:
  • Phone: 505-659-8307
  • Fax:
Mailing address:
  • Phone: 505-659-8307
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number61064
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: