Provider Demographics
NPI:1881304301
Name:VELAZQUEZ, MARTHA LORENA
Entity type:Individual
Prefix:
First Name:MARTHA
Middle Name:LORENA
Last Name:VELAZQUEZ
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 1:4545 N 67TH AVE UNIT 2444
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85033-1666
Mailing Address - Country:US
Mailing Address - Phone:480-468-2902
Mailing Address - Fax:
Practice Address - Street 1:4545 N 67TH AVE UNIT 2444
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85033-1666
Practice Address - Country:US
Practice Address - Phone:480-468-2902
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-28
Last Update Date:2022-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ305S00000X305S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305S00000XManaged Care OrganizationsPoint of Service