Provider Demographics
NPI:1760186258
Name:MARTIN, BEVERLY GRACE
Entity Type:Individual
Prefix:
First Name:BEVERLY
Middle Name:GRACE
Last Name:MARTIN
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 1:813 ADELITA ST
Mailing Address - Street 2:
Mailing Address - City:MONTEBELLO
Mailing Address - State:CA
Mailing Address - Zip Code:90640-2504
Mailing Address - Country:US
Mailing Address - Phone:213-804-0055
Mailing Address - Fax:
Practice Address - Street 1:813 ADELITA ST
Practice Address - Street 2:
Practice Address - City:MONTEBELLO
Practice Address - State:CA
Practice Address - Zip Code:90640-2504
Practice Address - Country:US
Practice Address - Phone:213-804-0055
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-28
Last Update Date:2023-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAVN169181164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse