Provider Demographics
NPI:1316249147
Name:MARTINEZ, VIVIAN D (LPN)
Entity type:Individual
Prefix:
First Name:VIVIAN
Middle Name:D
Last Name:MARTINEZ
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. DRAWER PH
Mailing Address - Street 2:CHINLE COMPREHENSIVE HEALTH CARE FACILITY
Mailing Address - City:CHINLE
Mailing Address - State:AZ
Mailing Address - Zip Code:86503
Mailing Address - Country:US
Mailing Address - Phone:928-674-7205
Mailing Address - Fax:928-674-7705
Practice Address - Street 1:HIGHWAY 191 & HOSPITAL ROAD
Practice Address - Street 2:CHINLE COMPREHENSIVE HEALTH CARE FACILITY
Practice Address - City:CHINLE
Practice Address - State:AZ
Practice Address - Zip Code:86503
Practice Address - Country:US
Practice Address - Phone:928-674-7205
Practice Address - Fax:928-674-7705
Is Sole Proprietor?:No
Enumeration Date:2010-11-30
Last Update Date:2010-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO055791164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO055791OtherSTATE BOARD OF NURSING LICENSE