Provider Demographics
NPI:1609101997
Name:MARTINEZ, CAROLYN MOSS (FNP)
Entity Type:Individual
Prefix:
First Name:CAROLYN
Middle Name:MOSS
Last Name:MARTINEZ
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 459
Mailing Address - Street 2:
Mailing Address - City:IMPERIAL BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:91933-0459
Mailing Address - Country:US
Mailing Address - Phone:619-429-3733
Mailing Address - Fax:619-429-3733
Practice Address - Street 1:1016 OUTER RD
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92154
Practice Address - Country:US
Practice Address - Phone:619-429-3733
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-10-05
Last Update Date:2018-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA22031363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily