Healthcare Provider Details

I. General information

NPI: 1578635140
Provider Name (Legal Business Name): MILDRED M MARTINEZ NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/15/2006
Last Update Date: 01/24/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

861 CORONADO CENTER DR STE 220
HENDERSON NV
89052-3992
US

IV. Provider business mailing address

2900 W HORIZON RIDGE PKWY STE 100
HENDERSON NV
89052-5014
US

V. Phone/Fax

Practice location:
  • Phone: 702-357-8811
  • Fax: 702-947-5352
Mailing address:
  • Phone: 702-357-8811
  • Fax: 702-947-5352

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number13396
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License NumberAPRN000964
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: