Healthcare Provider Details

I. General information

NPI: 1083637680
Provider Name (Legal Business Name): KIMBERLY MARIE MARTINEZ ANP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/25/2006
Last Update Date: 03/05/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2700 SE STRATUS AVE UNIT 304
MCMINNVILLE OR
97128-6257
US

IV. Provider business mailing address

2700 SE STRATUS AVE UNIT 304
MCMINNVILLE OR
97128-6257
US

V. Phone/Fax

Practice location:
  • Phone: 503-434-6090
  • Fax: 503-474-3306
Mailing address:
  • Phone: 503-434-6090
  • Fax: 503-474-3306

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number094006411N3
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: