Provider Demographics
NPI:1710669817
Name:HUACON, MARTHA M (RN)
Entity Type:Individual
Prefix:
First Name:MARTHA
Middle Name:M
Last Name:HUACON
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:MARTHA
Other - Middle Name:M
Other - Last Name:DE LA VEGA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:14319 KNOBCONE DR
Mailing Address - Street 2:
Mailing Address - City:PENN VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:95946-9519
Mailing Address - Country:US
Mailing Address - Phone:530-329-6156
Mailing Address - Fax:
Practice Address - Street 1:500 CROWN POINT CIR
Practice Address - Street 2:
Practice Address - City:GRASS VALLEY
Practice Address - State:CA
Practice Address - Zip Code:95945-9561
Practice Address - Country:US
Practice Address - Phone:530-470-2408
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-07
Last Update Date:2023-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95125466163WP0809X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0809XNursing Service ProvidersRegistered NursePsychiatric/Mental Health, Adult