Healthcare Provider Details

I. General information

NPI: 1700708450
Provider Name (Legal Business Name): MADELINE JUDITH MARTINCIC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/27/2026
Last Update Date: 07/27/2026
Certification Date: 07/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

446 OAK ST
BROOKINGS OR
97415-8802
US

IV. Provider business mailing address

1014 W FOX RUN AVE
SANTAQUIN UT
84655-4621
US

V. Phone/Fax

Practice location:
  • Phone: 541-412-8898
  • Fax:
Mailing address:
  • Phone: 435-979-3559
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number10063397
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: