=====================================================
General NPI Number Information
=====================================================
NPI Number | 1114694940
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | IVONNE MARTINEZ MORALES MT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/28/2021
-----------------------------------------------------
Last Update Date | 08/28/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5000 W NATIONAL AVE
-----------------------------------------------------
City | MILWAUKEE
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53295-0001
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 414-384-2000
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1227 LAMBETH RD APT 4
-----------------------------------------------------
City | WAUKESHA
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53189-7145
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 262-549-9923
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 246QM0706X
-----------------------------------------------------
Taxonomy Name | Medical Technologist
-----------------------------------------------------
License Number | 206046
-----------------------------------------------------
License Number State | PR
-----------------------------------------------------