Basic Information
| Provider Information | |||||||||
| NPI: | 1982126595 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MARTINEZ | ||||||||
| FirstName: | CARISSA | ||||||||
| MiddleName: | REANNA | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | FNP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | LOPEZ | ||||||||
| OtherFirstName: | CARISSA | ||||||||
| OtherMiddleName: | REANNA | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 4800 BASELINE RD STE D106 | ||||||||
| Address2: | |||||||||
| City: | BOULDER | ||||||||
| State: | CO | ||||||||
| PostalCode: | 803032643 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3034994800 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 4800 BASELINE RD STE D106 | ||||||||
| Address2: | |||||||||
| City: | BOULDER | ||||||||
| State: | CO | ||||||||
| PostalCode: | 803032643 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3034994800 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/14/2017 | ||||||||
| LastUpdateDate: | 09/14/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 09/14/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 0200426 | CO | N | Nursing Service Providers | Registered Nurse | 363L00000X | 0993330-NP | CO | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.