Provider Demographics
NPI:1588814263
Name:MARTIN, FONSHAY LATRICE (GNP-BC)
Entity Type:Individual
Prefix:MISS
First Name:FONSHAY
Middle Name:LATRICE
Last Name:MARTIN
Suffix:
Gender:F
Credentials:GNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:113 PLEASANT VALLEY DR STE 210
Mailing Address - Street 2:
Mailing Address - City:BOERNE
Mailing Address - State:TX
Mailing Address - Zip Code:78006-5683
Mailing Address - Country:US
Mailing Address - Phone:830-267-4575
Mailing Address - Fax:830-267-4575
Practice Address - Street 1:113 PLEASANT VALLEY DR STE 210
Practice Address - Street 2:
Practice Address - City:BOERNE
Practice Address - State:TX
Practice Address - Zip Code:78006-5683
Practice Address - Country:US
Practice Address - Phone:830-267-4575
Practice Address - Fax:830-267-4575
Is Sole Proprietor?:No
Enumeration Date:2008-09-30
Last Update Date:2023-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV860200363LG0600X
TXAP115919363LG0600X
TX705048363LG0600X
NM70334363LG0600X
KS5381716052363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX206653214Medicaid