Provider Demographics
NPI:1396191367
Name:MARTINEZ, MAYRA ISABEL
Entity Type:Individual
Prefix:
First Name:MAYRA
Middle Name:ISABEL
Last Name:MARTINEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1783 AMERICANA BLVD
Mailing Address - Street 2:
Mailing Address - City:BLUE MOUND
Mailing Address - State:TX
Mailing Address - Zip Code:76131-1131
Mailing Address - Country:US
Mailing Address - Phone:817-917-4633
Mailing Address - Fax:
Practice Address - Street 1:1783 AMERICANA BLVD
Practice Address - Street 2:
Practice Address - City:BLUE MOUND
Practice Address - State:TX
Practice Address - Zip Code:76131-1131
Practice Address - Country:US
Practice Address - Phone:817-917-4633
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-05-10
Last Update Date:2016-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXNA08926247376K00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No376K00000XNursing Service Related ProvidersNurse's Aide