MEDICARE: MARTHA CLEMENTINA VELASQUEZ

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	183700000X	Pharmacy Technician	RPT91036	FL

General Provider Information

NPI Number	:	1023614427
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARTHA CLEMENTINA VELASQUEZ

Provider Business Mailing Address
First Line	:	3708 LAURETTE LN
Second Line	:
City	:	LAKE WORTH
State	:	FL
Zip	:	33461-3449
Country	:	US
Telephone Number	:	561-568-3772
Fax Number	:

Provider Business Practice Location Address
First Line	:	2187 S MILITARY TRL
Second Line	:
City	:	WEST PALM BEACH
State	:	FL
Zip	:	33415-6453
Country	:	US
Telephone Number	:	561-641-6865
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/10/2020
Last Update Date	:	12/10/2020

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