Provider Demographics
NPI:1144574062
Name:WILLEY, MARTI L (NP)
Entity Type:Individual
Prefix:
First Name:MARTI
Middle Name:L
Last Name:WILLEY
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 25100
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93729-5100
Mailing Address - Country:US
Mailing Address - Phone:559-326-1222
Mailing Address - Fax:559-326-1230
Practice Address - Street 1:477 N EL CAMINO REAL STE D200
Practice Address - Street 2:
Practice Address - City:ENCINITAS
Practice Address - State:CA
Practice Address - Zip Code:92024-1375
Practice Address - Country:US
Practice Address - Phone:760-452-3340
Practice Address - Fax:760-452-3344
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-30
Last Update Date:2020-01-28
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CA22548363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA588647OtherRN MEDICAL LICENSE
CA22548OtherNURSE PRACTITIONER MEDICAL LICENSE
CAGT229ZOtherMEDICARE PTAN
CA2012003305OtherANCC NATIONAL CERTIFICATION