Provider Demographics
NPI:1629543640
Name:MARTINEZ, JEANNETT
Entity Type:Individual
Prefix:
First Name:JEANNETT
Middle Name:
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 1:123 GIRARD BLVD SE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87106-2227
Mailing Address - Country:US
Mailing Address - Phone:505-264-9454
Mailing Address - Fax:505-557-1941
Practice Address - Street 1:123 GIRARD BLVD SE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87106-2227
Practice Address - Country:US
Practice Address - Phone:505-726-4407
Practice Address - Fax:505-557-1941
Is Sole Proprietor?:No
Enumeration Date:2018-10-05
Last Update Date:2021-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMCNP-54246363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
525745613OtherNEW MEXICO