Provider Demographics
NPI:1376853879
Name:NANKIVELL, MARTINA (PAC)
Entity Type:Individual
Prefix:
First Name:MARTINA
Middle Name:
Last Name:NANKIVELL
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:320 PINE AVE STE 609
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90802-2310
Mailing Address - Country:US
Mailing Address - Phone:562-279-0180
Mailing Address - Fax:
Practice Address - Street 1:320 PINE AVE STE 609
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90802-2310
Practice Address - Country:US
Practice Address - Phone:562-279-0180
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-10-18
Last Update Date:2023-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA12836363A00000X
AZ7436363A00000X
NV2247363A00000X
FLPA9116057363A00000X
CAPA21291363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant