Provider Demographics
NPI:1417176322
Name:IZVERNARI, MARTHA KIM (NP)
Entity type:Individual
Prefix:MS
First Name:MARTHA
Middle Name:KIM
Last Name:IZVERNARI
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1695 S. SAN JACINTO AVE
Mailing Address - Street 2:SUITE L
Mailing Address - City:SAN JACINTO
Mailing Address - State:CA
Mailing Address - Zip Code:92583-5103
Mailing Address - Country:US
Mailing Address - Phone:951-654-8132
Mailing Address - Fax:951-654-8135
Practice Address - Street 1:1695 S. SAN JACINTO AVE
Practice Address - Street 2:SUITE L
Practice Address - City:SAN JACINTO
Practice Address - State:CA
Practice Address - Zip Code:92583-5103
Practice Address - Country:US
Practice Address - Phone:951-654-8132
Practice Address - Fax:951-654-8135
Is Sole Proprietor?:No
Enumeration Date:2007-04-25
Last Update Date:2010-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARN269257363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily