Healthcare Provider Details

I. General information

NPI: 1134156078
Provider Name (Legal Business Name): WANDA ELOISA MARTINEZ RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/27/2006
Last Update Date: 02/12/2021
Certification Date: 02/12/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

31ST & BATTELION AVE BENNETT HEALTH CLINIC BLD #420
FT HOOD TX
76544-4752
US

IV. Provider business mailing address

36065 SANTA FE AVE
FORT HOOD TX
76544-5060
US

V. Phone/Fax

Practice location:
  • Phone: 254-618-8067
  • Fax: 254-618-8099
Mailing address:
  • Phone: 254-618-8125
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC0400X
TaxonomyCase Management Registered Nurse
License Number642487
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: