Provider Demographics
NPI:1770191538
Name:MARTINEZ, DEIRDRE ANN (FNP)
Entity Type:Individual
Prefix:
First Name:DEIRDRE
Middle Name:ANN
Last Name:MARTINEZ
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:66 OXFORD DR
Mailing Address - Street 2:
Mailing Address - City:SAN RAFAEL
Mailing Address - State:CA
Mailing Address - Zip Code:94903-2887
Mailing Address - Country:US
Mailing Address - Phone:415-246-5409
Mailing Address - Fax:
Practice Address - Street 1:1179 N MCDOWELL BLVD
Practice Address - Street 2:
Practice Address - City:PETALUMA
Practice Address - State:CA
Practice Address - Zip Code:94954-6559
Practice Address - Country:US
Practice Address - Phone:707-559-7500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-17
Last Update Date:2023-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA2025223363LF0000X
390200000X
CA95022828363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program