Provider Demographics
NPI:1285078113
Name:MARTINE, FERN
Entity type:Individual
Prefix:
First Name:FERN
Middle Name:
Last Name:MARTINE
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 1:724 W 1720 N
Mailing Address - Street 2:#211
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84604-2486
Mailing Address - Country:US
Mailing Address - Phone:801-494-1070
Mailing Address - Fax:
Practice Address - Street 1:1169 E 1010 N
Practice Address - Street 2:
Practice Address - City:SPANISH FORK
Practice Address - State:UT
Practice Address - Zip Code:84660-5507
Practice Address - Country:US
Practice Address - Phone:801-851-7661
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-22
Last Update Date:2013-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator