Basic Information
| Provider Information | |||||||||
| NPI: | 1871095687 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PORTILLO | ||||||||
| FirstName: | MARTINA | ||||||||
| MiddleName: | JENKINS | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | R.N, MPH | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | CALLAGHAN | ||||||||
| OtherFirstName: | MARTINA | ||||||||
| OtherMiddleName: | P | ||||||||
| OtherNamePrefix: | MRS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 406 | ||||||||
| Address2: | |||||||||
| City: | PAUMA VALLEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 920610406 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7607491410 | ||||||||
| FaxNumber: | 7607494122 | ||||||||
| Practice Location | |||||||||
| Address1: | 50100 GOLSH RD | ||||||||
| Address2: | |||||||||
| City: | VALLEY CENTER | ||||||||
| State: | CA | ||||||||
| PostalCode: | 920825338 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7607491410 | ||||||||
| FaxNumber: | 7607494122 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/07/2018 | ||||||||
| LastUpdateDate: | 03/07/2018 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNameSuffix: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WC1500X | 219534 | CA | Y | Nursing Service Providers | Registered Nurse | Community Health |
No ID Information.