Provider Demographics
NPI:1023673266
Name:MARTIN, MARQUITA LATORIA
Entity type:Individual
Prefix:
First Name:MARQUITA
Middle Name:LATORIA
Last Name:MARTIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MARQUITA
Other - Middle Name:LATORIA
Other - Last Name:MARTIN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:178 NAUTICO WAY
Mailing Address - Street 2:
Mailing Address - City:PORTSMOUTH
Mailing Address - State:VA
Mailing Address - Zip Code:23703-5469
Mailing Address - Country:US
Mailing Address - Phone:757-920-9420
Mailing Address - Fax:757-484-7256
Practice Address - Street 1:178 NAUTICO WAY
Practice Address - Street 2:
Practice Address - City:PORTSMOUTH
Practice Address - State:VA
Practice Address - Zip Code:23703-5469
Practice Address - Country:US
Practice Address - Phone:757-920-9420
Practice Address - Fax:757-484-7256
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-02
Last Update Date:2019-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA46955172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver