Provider Demographics
NPI:1841559838
Name:VELASCO, MARTHA DANIELLA
Entity Type:Individual
Prefix:
First Name:MARTHA
Middle Name:DANIELLA
Last Name:VELASCO
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 1:8159 SAILOR POINT AVE
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89147-3766
Mailing Address - Country:US
Mailing Address - Phone:702-451-7542
Mailing Address - Fax:
Practice Address - Street 1:4660 S EASTERN AVE
Practice Address - Street 2:STE 200
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89119-6137
Practice Address - Country:US
Practice Address - Phone:702-451-7542
Practice Address - Fax:702-450-4239
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-10
Last Update Date:2012-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker