Provider Demographics
NPI:1093695108
Name:MARTIN, MARIAH NICOLE
Entity type:Individual
Prefix:
First Name:MARIAH
Middle Name:NICOLE
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 1:5809 W AVENUE K14
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:CA
Mailing Address - Zip Code:93536-5629
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:627 W AVENUE Q STE D
Practice Address - Street 2:
Practice Address - City:PALMDALE
Practice Address - State:CA
Practice Address - Zip Code:93551-3891
Practice Address - Country:US
Practice Address - Phone:661-272-5656
Practice Address - Fax:661-272-0909
Is Sole Proprietor?:Yes
Enumeration Date:2025-09-08
Last Update Date:2025-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95117432363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily