Healthcare Provider Details

I. General information

NPI: 1306759238
Provider Name (Legal Business Name): MITZI TREVINO LPN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MITZI MARTINEZLOPEZ

II. Dates (important events)

Enumeration Date: 09/23/2026
Last Update Date: 09/23/2026
Certification Date: 09/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

121 GREEN ST
KINGSTON NY
12401-0403
US

IV. Provider business mailing address

121 GREEN ST
KINGSTON NY
12401-0403
US

V. Phone/Fax

Practice location:
  • Phone: 508-369-2988
  • Fax:
Mailing address:
  • Phone: 508-369-2988
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number12020
License Number StateRI
# 2
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number354562
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: