Basic Information
Provider Information | |||||||||
NPI: | 1588255574 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MARTINEZ | ||||||||
FirstName: | ELISE | ||||||||
MiddleName: | CORY | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | NP | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | RODRIGUEZ | ||||||||
OtherFirstName: | ELISE | ||||||||
OtherMiddleName: | CORY | ||||||||
OtherNamePrefix: | MISS | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | NP | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 2147 | ||||||||
Address2: |   | ||||||||
City: | FORT MYERS | ||||||||
State: | FL | ||||||||
PostalCode: | 339022147 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2393439567 | ||||||||
FaxNumber: | 2393439571 | ||||||||
Practice Location | |||||||||
Address1: | 8925 COLONIAL CENTER DR STE 2001 | ||||||||
Address2: |   | ||||||||
City: | FORT MYERS | ||||||||
State: | FL | ||||||||
PostalCode: | 339057813 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2393439567 | ||||||||
FaxNumber: | 2393439571 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/01/2021 | ||||||||
LastUpdateDate: | 12/10/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 12/10/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 5014029 | NC | N |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 163WX0200X | 247724 | NC | N |   | Nursing Service Providers | Registered Nurse | Oncology | 363LF0000X | APRN11016007 | FL | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
ID | Type | State | Issuer | Description | 112257400 | 05 | FL |   | MEDICAID |