Healthcare Provider Details

I. General information

NPI: 1912832668
Provider Name (Legal Business Name): LISA ANN MARTINEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/15/2026
Last Update Date: 06/15/2026
Certification Date: 06/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

530 BOGACHIEL WAY
FORKS WA
98331-9120
US

IV. Provider business mailing address

530 BOGACHIEL WAY
FORKS WA
98331-9120
US

V. Phone/Fax

Practice location:
  • Phone: 360-374-5011
  • Fax: 360-374-6691
Mailing address:
  • Phone: 360-374-5011
  • Fax: 360-374-6691

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number91-6001732
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: