Provider Demographics
NPI:1407665565
Name:MARTINEZ, CONNIE
Entity type:Individual
Prefix:
First Name:CONNIE
Middle Name:
Last Name: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 1:10924 EXPLORER RD
Mailing Address - Street 2:
Mailing Address - City:LA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:91941-7221
Mailing Address - Country:US
Mailing Address - Phone:424-381-7710
Mailing Address - Fax:
Practice Address - Street 1:7545 METROPOLITAN DR
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92108-4402
Practice Address - Country:US
Practice Address - Phone:844-347-7306
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-01-03
Last Update Date:2025-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAVN724308164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse