Provider Demographics
NPI:1457764268
Name:MARTINEZ, SHANNON VICTORIA
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:VICTORIA
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 1:7818 81ST ST
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:NY
Mailing Address - Zip Code:11385-7633
Mailing Address - Country:US
Mailing Address - Phone:347-737-7018
Mailing Address - Fax:
Practice Address - Street 1:7818 81ST ST
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:NY
Practice Address - Zip Code:11385-7633
Practice Address - Country:US
Practice Address - Phone:347-737-7018
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-09
Last Update Date:2014-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist