=====================================================
General NPI Number Information
=====================================================
NPI Number | 1720618788
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SHANA LYNN MARTINEZ
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/18/2020
-----------------------------------------------------
Last Update Date | 10/09/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 623 W NORTH STREET
-----------------------------------------------------
City | MADRID
-----------------------------------------------------
State | IA
-----------------------------------------------------
Zip | 50156-1023
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 515-795-4300
-----------------------------------------------------
Fax | 515-795-4145
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1015 UNION STREET
-----------------------------------------------------
City | BOONE
-----------------------------------------------------
State | IA
-----------------------------------------------------
Zip | 50036-4821
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 515-248-1447
-----------------------------------------------------
Fax | 515-248-1440
-----------------------------------------------------
=====================================================
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 | A157506
-----------------------------------------------------
License Number State | IA
-----------------------------------------------------