Provider Demographics
NPI:1194366906
Name:PONCE, MARTYNA
Entity type:Individual
Prefix:
First Name:MARTYNA
Middle Name:
Last Name:PONCE
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 1:80 S MAPLE AVE
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:NJ
Mailing Address - Zip Code:07081-1906
Mailing Address - Country:US
Mailing Address - Phone:973-376-4182
Mailing Address - Fax:
Practice Address - Street 1:10616 S JACOB SMART BLVD STE 104
Practice Address - Street 2:
Practice Address - City:RIDGELAND
Practice Address - State:SC
Practice Address - Zip Code:29936-8478
Practice Address - Country:US
Practice Address - Phone:843-726-6600
Practice Address - Fax:843-717-2232
Is Sole Proprietor?:No
Enumeration Date:2019-10-02
Last Update Date:2024-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA296510225100000X
225100000X
SCCP032508T225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCCP032508TOtherPT LICENSE