Provider Demographics
NPI:1285402933
Name:VILLALTA MARTINEZ, JULISSA ABIGAIL
Entity type:Individual
Prefix:
First Name:JULISSA
Middle Name:ABIGAIL
Last Name:VILLALTA MARTINEZ
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 1:5 CLARKE ST
Mailing Address - Street 2:
Mailing Address - City:BRENTWOOD
Mailing Address - State:NY
Mailing Address - Zip Code:11717-2001
Mailing Address - Country:US
Mailing Address - Phone:631-575-9450
Mailing Address - Fax:
Practice Address - Street 1:5 CLARKE ST
Practice Address - Street 2:
Practice Address - City:BRENTWOOD
Practice Address - State:NY
Practice Address - Zip Code:11717-2001
Practice Address - Country:US
Practice Address - Phone:631-575-9450
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-12-12
Last Update Date:2023-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY349090-01164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse