Provider Demographics
NPI:1881366169
Name:MARTINEZ-VAN BOKKEM, CAROLA JEANNETTE
Entity type:Individual
Prefix:
First Name:CAROLA
Middle Name:JEANNETTE
Last Name:MARTINEZ-VAN BOKKEM
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 1:301 FRONT ST
Mailing Address - Street 2:
Mailing Address - City:NYACK
Mailing Address - State:NY
Mailing Address - Zip Code:10960-1405
Mailing Address - Country:US
Mailing Address - Phone:917-288-9546
Mailing Address - Fax:
Practice Address - Street 1:301 FRONT ST
Practice Address - Street 2:
Practice Address - City:NYACK
Practice Address - State:NY
Practice Address - Zip Code:10960-1405
Practice Address - Country:US
Practice Address - Phone:917-288-9546
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-04
Last Update Date:2021-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1435498201174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty