Provider Demographics
NPI:1043701725
Name:MARTINEZ VASQUEZ, TRACEE MARIE (ED M)
Entity Type:Individual
Prefix:
First Name:TRACEE
Middle Name:MARIE
Last Name:MARTINEZ VASQUEZ
Suffix:
Gender:F
Credentials:ED M
Other - Prefix:
Other - First Name:TRACEE
Other - Middle Name:MARIE
Other - Last Name:SANTOS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:232 HEBERTON AVE
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10302-1807
Mailing Address - Country:US
Mailing Address - Phone:917-446-7077
Mailing Address - Fax:
Practice Address - Street 1:232 HEBERTON AVE
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10302-1807
Practice Address - Country:US
Practice Address - Phone:917-446-7077
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-29
Last Update Date:2018-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist