Healthcare Provider Details

I. General information

NPI: 1053827675
Provider Name (Legal Business Name): CECILIA ANN MARTIN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/19/2017
Last Update Date: 12/19/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1250 WATERS PL
BRONX NY
10461-2720
US

IV. Provider business mailing address

PO BOX 467
WHITE PLAINS NY
10602-0467
US

V. Phone/Fax

Practice location:
  • Phone: 929-263-3302
  • Fax:
Mailing address:
  • Phone: 914-589-5628
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP2201X
TaxonomyAmbulatory Care Registered Nurse
License Number452839-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: