=====================================================
General NPI Number Information
=====================================================
NPI Number | 1538087218
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | STACIE ANN MARTIN APRN
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/09/2026
-----------------------------------------------------
Last Update Date | 07/09/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 516 W ATEN RD STE 2
-----------------------------------------------------
City | IMPERIAL
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92251-9805
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 619-961-8799
-----------------------------------------------------
Fax | 760-355-7731
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6154 CARLING WAY
-----------------------------------------------------
City | SAN DIEGO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92115-5528
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363L00000X
-----------------------------------------------------
Taxonomy Name | Nurse Practitioner
-----------------------------------------------------
License Number | 95039923
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------