Provider Demographics
NPI:1639715030
Name:MARTINEZ, MICHELLE JENNIFER
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:JENNIFER
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 1:204 HAMPTON DR
Mailing Address - Street 2:
Mailing Address - City:VENICE
Mailing Address - State:CA
Mailing Address - Zip Code:90291-8633
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:204 HAMPTON DR
Practice Address - Street 2:
Practice Address - City:VENICE
Practice Address - State:CA
Practice Address - Zip Code:90291-8633
Practice Address - Country:US
Practice Address - Phone:310-309-6001
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-20
Last Update Date:2023-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
CA172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
No171M00000XOther Service ProvidersCase Manager/Care Coordinator