Basic Information
| Provider Information | |||||||||
| NPI: | 1316249147 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MARTINEZ | ||||||||
| FirstName: | VIVIAN | ||||||||
| MiddleName: | D. | ||||||||
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| Credential: | LPN | ||||||||
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| Mailing Information | |||||||||
| Address1: | P.O. DRAWER PH | ||||||||
| Address2: | CHINLE COMPREHENSIVE HEALTH CARE FACILITY | ||||||||
| City: | CHINLE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 86503 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9286747205 | ||||||||
| FaxNumber: | 9286747705 | ||||||||
| Practice Location | |||||||||
| Address1: | HIGHWAY 191 & HOSPITAL ROAD | ||||||||
| Address2: | CHINLE COMPREHENSIVE HEALTH CARE FACILITY | ||||||||
| City: | CHINLE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 86503 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9286747205 | ||||||||
| FaxNumber: | 9286747705 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/30/2010 | ||||||||
| LastUpdateDate: | 11/30/2010 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 164W00000X | 055791 | MO | Y | Nursing Service Providers | Licensed Practical Nurse |
ID Information
| ID | Type | State | Issuer | Description | 055791 | 01 | MO | STATE BOARD OF NURSING LICENSE | OTHER |