Basic Information
| Provider Information | |||||||||
| NPI: | 1063813962 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MARTINEZ | ||||||||
| FirstName: | TIFFANY | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | PMHNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 7291 | ||||||||
| Address2: | |||||||||
| City: | LEWISTON | ||||||||
| State: | ME | ||||||||
| PostalCode: | 042437291 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2077778553 | ||||||||
| FaxNumber: | 2077778800 | ||||||||
| Practice Location | |||||||||
| Address1: | 93 CAMPUS AVE | ||||||||
| Address2: | |||||||||
| City: | LEWISTON | ||||||||
| State: | ME | ||||||||
| PostalCode: | 04240 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2077778700 | ||||||||
| FaxNumber: | 2077778826 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/10/2014 | ||||||||
| LastUpdateDate: | 07/10/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 364SC1501X | CNP141057 | ME | N | Physician Assistants & Advanced Practice Nursing Providers | Clinical Nurse Specialist | Community Health/Public Health | 363LP0808X | CNP141057 | ME | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health |
No ID Information.