Basic Information
| Provider Information | |||||||||
| NPI: | 1316568405 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MARTINEZ | ||||||||
| FirstName: | KIMBERLY | ||||||||
| MiddleName: | ANN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 248 E HIGHLAND AVE | ||||||||
| Address2: | |||||||||
| City: | REDLANDS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923736822 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9096477121 | ||||||||
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| Practice Location | |||||||||
| Address1: | 26520 CACTUS AVE | ||||||||
| Address2: | |||||||||
| City: | MORENO VALLEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 92555 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9514864000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/30/2020 | ||||||||
| LastUpdateDate: | 05/19/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/19/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | 95001318 | CA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
No ID Information.