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
State | License ID | Taxonomies |
---|---|---|
NV | 860200 | 363LG0600X |
TX | AP115919 | 363LG0600X |
TX | 705048 | 363LG0600X |
NM | 70334 | 363LG0600X |
KS | 5381716052 | 363LG0600X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 363LG0600X | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Gerontology |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
TX | 206653214 | Medicaid |