Provider Demographics
NPI:1952945230
Name:MARTIN, KAYLIN RENAE
Entity Type:Individual
Prefix:
First Name:KAYLIN
Middle Name:RENAE
Last Name:MARTIN
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 1:232 BUCCANEER LOOP
Mailing Address - Street 2:
Mailing Address - City:CLOVIS
Mailing Address - State:NM
Mailing Address - Zip Code:88101-2503
Mailing Address - Country:US
Mailing Address - Phone:573-219-8613
Mailing Address - Fax:
Practice Address - Street 1:232 BUCCANEER LOOP
Practice Address - Street 2:
Practice Address - City:CLOVIS
Practice Address - State:NM
Practice Address - Zip Code:88101-2503
Practice Address - Country:US
Practice Address - Phone:573-219-8613
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-30
Last Update Date:2019-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician