Provider Demographics
NPI:1063102903
Name:MARTIN, DANIELLE
Entity type:Individual
Prefix:
First Name:DANIELLE
Middle Name:
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 1:2841 FREEPORT BLVD
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95818-3049
Mailing Address - Country:US
Mailing Address - Phone:916-747-9192
Mailing Address - Fax:
Practice Address - Street 1:1011 22ND ST
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95816-4907
Practice Address - Country:US
Practice Address - Phone:916-284-1416
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-12
Last Update Date:2024-12-16
Deactivation Date:2023-08-19
Deactivation Code:
Reactivation Date:2024-07-19
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program