Provider Demographics
NPI:1871199802
Name:MARTINEZ, BRIANDA BLANCA
Entity Type:Individual
Prefix:
First Name:BRIANDA
Middle Name:BLANCA
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 1:124 COCOANUT ST
Mailing Address - Street 2:
Mailing Address - City:BRENTWOOD
Mailing Address - State:NY
Mailing Address - Zip Code:11717-7204
Mailing Address - Country:US
Mailing Address - Phone:631-398-1921
Mailing Address - Fax:
Practice Address - Street 1:124 COCOANUT ST
Practice Address - Street 2:
Practice Address - City:BRENTWOOD
Practice Address - State:NY
Practice Address - Zip Code:11717-7204
Practice Address - Country:US
Practice Address - Phone:631-398-1921
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-06
Last Update Date:2020-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY340245164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse