Provider Demographics
NPI:1053975110
Name:MARTINEZ, MARISOL
Entity type:Individual
Prefix:
First Name:MARISOL
Middle Name:
Last Name:MARTINEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MARISOL
Other - Middle Name:
Other - Last Name:MARTINEZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:845 E ARROW HWY
Mailing Address - Street 2:
Mailing Address - City:POMONA
Mailing Address - State:CA
Mailing Address - Zip Code:91767-2535
Mailing Address - Country:US
Mailing Address - Phone:909-624-1233
Mailing Address - Fax:909-445-8439
Practice Address - Street 1:845 E ARROW HWY
Practice Address - Street 2:
Practice Address - City:POMONA
Practice Address - State:CA
Practice Address - Zip Code:91767-2535
Practice Address - Country:US
Practice Address - Phone:909-624-1233
Practice Address - Fax:909-445-8439
Is Sole Proprietor?:No
Enumeration Date:2019-04-24
Last Update Date:2019-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA700785164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse