Provider Demographics
NPI:1114208139
Name:MARTINEZ, KERI (NURSE PRACTITIONER)
Entity type:Individual
Prefix:MS
First Name:KERI
Middle Name:
Last Name:MARTINEZ
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 NICOLLS RD
Mailing Address - Street 2:
Mailing Address - City:STONY BROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11794-0001
Mailing Address - Country:US
Mailing Address - Phone:631-444-2078
Mailing Address - Fax:631-638-1199
Practice Address - Street 1:100 NICOLLS RD
Practice Address - Street 2:
Practice Address - City:STONY BROOK
Practice Address - State:NY
Practice Address - Zip Code:11794-2107
Practice Address - Country:US
Practice Address - Phone:631-444-2078
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-09-03
Last Update Date:2024-10-01
Deactivation Date:2024-09-17
Deactivation Code:
Reactivation Date:2024-09-26
Provider Licenses
StateLicense IDTaxonomies
NYF311893363LA2200X
NY306190164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No164X00000XNursing Service ProvidersLicensed Vocational Nurse