Basic Information
| Provider Information | |||||||||
| NPI: | 1114467776 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MARTINEZ | ||||||||
| FirstName: | CONNIE | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | ARNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 746724 | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303746724 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9199807008 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4600 CAPITAL BLVD | ||||||||
| Address2: | |||||||||
| City: | RALEIGH | ||||||||
| State: | NC | ||||||||
| PostalCode: | 276044478 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9199807008 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/02/2017 | ||||||||
| LastUpdateDate: | 04/28/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 04/28/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | ARNP 9180821 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.