Provider Demographics
NPI:1457823361
Name:MARTINEZ, ELISE JOELLE (RN)
Entity Type:Individual
Prefix:
First Name:ELISE
Middle Name:JOELLE
Last Name:MARTINEZ
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1754 AVENIDA ENTRADA
Mailing Address - Street 2:
Mailing Address - City:SAN DIMAS
Mailing Address - State:CA
Mailing Address - Zip Code:91773-4301
Mailing Address - Country:US
Mailing Address - Phone:909-996-8774
Mailing Address - Fax:
Practice Address - Street 1:1060 E FOOTHILL BLVD STE 103
Practice Address - Street 2:
Practice Address - City:UPLAND
Practice Address - State:CA
Practice Address - Zip Code:91786-4070
Practice Address - Country:US
Practice Address - Phone:909-981-8904
Practice Address - Fax:909-981-8943
Is Sole Proprietor?:No
Enumeration Date:2018-12-18
Last Update Date:2019-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95072251163W00000X
CA95011216363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
No163W00000XNursing Service ProvidersRegistered Nurse