Provider Demographics
NPI:1619732419
Name:MARTINEZ, SERENA ANGELINA
Entity Type:Individual
Prefix:
First Name:SERENA
Middle Name:ANGELINA
Last Name:MARTINEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25910 ACERO STE 160
Mailing Address - Street 2:
Mailing Address - City:MISSION VIEJO
Mailing Address - State:CA
Mailing Address - Zip Code:92691-2777
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1661 N RAYMOND AVE STE
Practice Address - Street 2:200
Practice Address - City:ANAHEIM
Practice Address - State:CA
Practice Address - Zip Code:92801-1120
Practice Address - Country:US
Practice Address - Phone:877-527-7227
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-20
Last Update Date:2024-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator