Provider Demographics
NPI:1821604117
Name:HIPOLITO, MARTHA A
Entity Type:Individual
Prefix:
First Name:MARTHA
Middle Name:A
Last Name:HIPOLITO
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 1:1110 FAIRBANKS AVE
Mailing Address - Street 2:
Mailing Address - City:YAKIMA
Mailing Address - State:WA
Mailing Address - Zip Code:98902-2012
Mailing Address - Country:US
Mailing Address - Phone:323-547-4338
Mailing Address - Fax:
Practice Address - Street 1:1110 FAIRBANKS AVE
Practice Address - Street 2:
Practice Address - City:YAKIMA
Practice Address - State:WA
Practice Address - Zip Code:98902-2012
Practice Address - Country:US
Practice Address - Phone:323-547-4338
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-22
Last Update Date:2020-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WASC12188171R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171R00000XOther Service ProvidersInterpreter
Provider Identifiers
StateIdentifier IDID TypeIssuer
WASC12188OtherSPANISH INTERPRETER