Provider Demographics
NPI:1821037391
Name:MARTINEZ, SHIRLEY MEDINA
Entity Type:Individual
Prefix:
First Name:SHIRLEY
Middle Name:MEDINA
Last Name:MARTINEZ
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 1:1517 SARATOGA DR
Mailing Address - Street 2:
Mailing Address - City:ALPHARETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30022-2887
Mailing Address - Country:US
Mailing Address - Phone:678-461-0179
Mailing Address - Fax:
Practice Address - Street 1:1517 SARATOGA DR
Practice Address - Street 2:
Practice Address - City:ALPHARETTA
Practice Address - State:GA
Practice Address - Zip Code:30022-2887
Practice Address - Country:US
Practice Address - Phone:678-461-0179
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA01025076172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver