Provider Demographics
NPI:1063813962
Name:MARTINEZ, TIFFANY M (PMHNP)
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:M
Last Name:MARTINEZ
Suffix:
Gender:F
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 7291
Mailing Address - Street 2:
Mailing Address - City:LEWISTON
Mailing Address - State:ME
Mailing Address - Zip Code:04243-7291
Mailing Address - Country:US
Mailing Address - Phone:207-777-8553
Mailing Address - Fax:207-777-8800
Practice Address - Street 1:93 CAMPUS AVE
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:ME
Practice Address - Zip Code:04240
Practice Address - Country:US
Practice Address - Phone:207-777-8700
Practice Address - Fax:207-777-8826
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-10
Last Update Date:2018-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MECNP141057364SC1501X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No364SC1501XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistCommunity Health/Public Health