Healthcare Provider Details

I. General information

NPI: 1023673266
Provider Name (Legal Business Name): MARQUITA LATORIA MARTIN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MARQUITA LATORIA MARTIN

II. Dates (important events)

Enumeration Date: 05/02/2019
Last Update Date: 05/02/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

178 NAUTICO WAY
PORTSMOUTH VA
23703-5469
US

IV. Provider business mailing address

178 NAUTICO WAY
PORTSMOUTH VA
23703-5469
US

V. Phone/Fax

Practice location:
  • Phone: 757-920-9420
  • Fax: 757-484-7256
Mailing address:
  • Phone: 757-920-9420
  • Fax: 757-484-7256

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172A00000X
TaxonomyDriver
License Number46955
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: