Provider Demographics
NPI:1003647884
Name:MARTENSEN, FALLON KATHLEEN
Entity type:Individual
Prefix:
First Name:FALLON
Middle Name:KATHLEEN
Last Name:MARTENSEN
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 1:35 THE MOOR
Mailing Address - Street 2:
Mailing Address - City:EAST ISLIP
Mailing Address - State:NY
Mailing Address - Zip Code:11730-2922
Mailing Address - Country:US
Mailing Address - Phone:631-704-0930
Mailing Address - Fax:
Practice Address - Street 1:35 THE MOOR
Practice Address - Street 2:
Practice Address - City:EAST ISLIP
Practice Address - State:NY
Practice Address - Zip Code:11730-2922
Practice Address - Country:US
Practice Address - Phone:631-704-0930
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-12
Last Update Date:2024-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist