Provider Demographics
NPI:1407248495
Name:MARTIN, SHUNTE ERNLYNN
Entity Type:Individual
Prefix:MRS
First Name:SHUNTE
Middle Name:ERNLYNN
Last Name:MARTIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:SHUNTE
Other - Middle Name:ERNLYNN
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LVN
Mailing Address - Street 1:81066 MILES AVE
Mailing Address - Street 2:
Mailing Address - City:INDIO
Mailing Address - State:CA
Mailing Address - Zip Code:92201-2820
Mailing Address - Country:US
Mailing Address - Phone:760-979-3095
Mailing Address - Fax:
Practice Address - Street 1:47915 OASIS ST
Practice Address - Street 2:
Practice Address - City:INDIO
Practice Address - State:CA
Practice Address - Zip Code:92201-6950
Practice Address - Country:US
Practice Address - Phone:760-863-8600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-02-27
Last Update Date:2015-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAVN 234485164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse