Provider Demographics
NPI:1760944409
Name:MARTINEZ, MARCELA LOPEZ X
Entity Type:Individual
Prefix:
First Name:MARCELA
Middle Name:LOPEZ
Last Name:MARTINEZ
Suffix:X
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 1:2203 OLD HWY 99 S
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:WA
Mailing Address - Zip Code:98273-9009
Mailing Address - Country:US
Mailing Address - Phone:360-542-8810
Mailing Address - Fax:
Practice Address - Street 1:2203 OLD HWY 99 S
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:WA
Practice Address - Zip Code:98273-9009
Practice Address - Country:US
Practice Address - Phone:360-542-8810
Practice Address - Fax:360-542-8811
Is Sole Proprietor?:No
Enumeration Date:2019-04-02
Last Update Date:2019-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAWDL1855B093BMedicaid
WAWDL1855B09BMedicaid