Provider Demographics
NPI:1770935066
Name:MARTINEZ, CELESTE ITZEL
Entity type:Individual
Prefix:
First Name:CELESTE
Middle Name:ITZEL
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 1:5115 NE 94TH AVE
Mailing Address - Street 2:STE D
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98662-6180
Mailing Address - Country:US
Mailing Address - Phone:360-977-6090
Mailing Address - Fax:
Practice Address - Street 1:5115 NE 94TH AVE
Practice Address - Street 2:STE D
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98662-6180
Practice Address - Country:US
Practice Address - Phone:360-977-6090
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-11
Last Update Date:2016-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60629301172M00000X
OR22308172M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172M00000XOther Service ProvidersMechanotherapist