=====================================================
General NPI Number Information
=====================================================
NPI Number | 1982335865
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LEALA ADEL MARTINEZ FNP-BC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/21/2022
-----------------------------------------------------
Last Update Date | 06/21/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 101 COLE AVE
-----------------------------------------------------
City | BISBEE
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85603-1327
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 520-432-2216
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5455 S APACHE AVE
-----------------------------------------------------
City | SIERRA VISTA
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85650-9714
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 252-622-7609
-----------------------------------------------------
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 | TEMP276414
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------