Provider Demographics
NPI:1558150581
Name:MARTINEZ, MIKAELA
Entity type:Individual
Prefix:
First Name:MIKAELA
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 1:2722 E 1ST ST
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90803-2550
Mailing Address - Country:US
Mailing Address - Phone:818-322-9056
Mailing Address - Fax:
Practice Address - Street 1:30125 AGOURA RD STE F
Practice Address - Street 2:
Practice Address - City:AGOURA
Practice Address - State:CA
Practice Address - Zip Code:91301-4337
Practice Address - Country:US
Practice Address - Phone:818-322-9056
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-05-05
Last Update Date:2025-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA133N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist