Provider Demographics
NPI:1285285114
Name:VERGARA, MARTHA MARLENE
Entity type:Individual
Prefix:
First Name:MARTHA
Middle Name:MARLENE
Last Name:VERGARA
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 1:44937 CAMOLIN AVE
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:CA
Mailing Address - Zip Code:93534-2019
Mailing Address - Country:US
Mailing Address - Phone:661-839-8258
Mailing Address - Fax:
Practice Address - Street 1:506 W JACKMAN ST
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:CA
Practice Address - Zip Code:93534-2531
Practice Address - Country:US
Practice Address - Phone:661-726-2850
Practice Address - Fax:661-726-2854
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-23
Last Update Date:2019-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CANA390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program