Provider Demographics
NPI:1679832117
Name:MARTINEZ, MARYANNE (RN)
Entity Type:Individual
Prefix:
First Name:MARYANNE
Middle Name:
Last Name:MARTINEZ
Suffix:
Gender:F
Credentials:RN
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 99
Mailing Address - Street 2:
Mailing Address - City:SAN LUIS
Mailing Address - State:CO
Mailing Address - Zip Code:81152-0099
Mailing Address - Country:US
Mailing Address - Phone:719-672-3332
Mailing Address - Fax:719-672-3856
Practice Address - Street 1:233 MAIN STREET
Practice Address - Street 2:SUITE C
Practice Address - City:SAN LUIS
Practice Address - State:CO
Practice Address - Zip Code:81152
Practice Address - Country:US
Practice Address - Phone:719-672-3332
Practice Address - Fax:719-672-3856
Is Sole Proprietor?:No
Enumeration Date:2012-05-03
Last Update Date:2012-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CORN-104428163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse