=====================================================
General NPI Number Information
=====================================================
NPI Number | 1225795313
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LAUREN DAVILA MARTINEZ CFNP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/23/2021
-----------------------------------------------------
Last Update Date | 03/18/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3533 S ALAMEDA STREET
-----------------------------------------------------
City | CORPUS CHRISTI
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78411
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 361-694-5000
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 277 BUDDY GANEM DR STE A
-----------------------------------------------------
City | PORTLAND
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78374-3202
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 361-777-3900
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | 1059321
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------