Provider Demographics
NPI:1730454778
Name:MARTINEZ, VIVIAN (LPN)
Entity type:Individual
Prefix:
First Name:VIVIAN
Middle Name:
Last Name:MARTINEZ
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9464 ELM ST
Mailing Address - Street 2:
Mailing Address - City:CHADWICKS
Mailing Address - State:NY
Mailing Address - Zip Code:13319-3519
Mailing Address - Country:US
Mailing Address - Phone:315-941-8167
Mailing Address - Fax:
Practice Address - Street 1:12 RHOADS DR
Practice Address - Street 2:
Practice Address - City:UTICA
Practice Address - State:NY
Practice Address - Zip Code:13502-6306
Practice Address - Country:US
Practice Address - Phone:315-798-4350
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-03-08
Last Update Date:2012-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY281261-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse