Provider Demographics
NPI:1982126595
Name:MARTINEZ, CARISSA REANNA (FNP)
Entity Type:Individual
Prefix:
First Name:CARISSA
Middle Name:REANNA
Last Name:MARTINEZ
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:CARISSA
Other - Middle Name:REANNA
Other - Last Name:LOPEZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4800 BASELINE RD STE D106
Mailing Address - Street 2:
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80303-2643
Mailing Address - Country:US
Mailing Address - Phone:303-499-4800
Mailing Address - Fax:
Practice Address - Street 1:4800 BASELINE RD STE D106
Practice Address - Street 2:
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80303-2643
Practice Address - Country:US
Practice Address - Phone:303-499-4800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-14
Last Update Date:2023-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0200426163W00000X
COAPN.0993330-NP363LF0000X
CO0993330-NP363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily