Provider Demographics
NPI:1871095687
Name:PORTILLO, MARTINA JENKINS (RN, MPH)
Entity type:Individual
Prefix:MS
First Name:MARTINA
Middle Name:JENKINS
Last Name:PORTILLO
Suffix:
Gender:F
Credentials:RN, MPH
Other - Prefix:MRS
Other - First Name:MARTINA
Other - Middle Name:P
Other - Last Name:CALLAGHAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 406
Mailing Address - Street 2:
Mailing Address - City:PAUMA VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92061-0406
Mailing Address - Country:US
Mailing Address - Phone:760-749-1410
Mailing Address - Fax:760-749-4122
Practice Address - Street 1:50100 GOLSH RD
Practice Address - Street 2:
Practice Address - City:VALLEY CENTER
Practice Address - State:CA
Practice Address - Zip Code:92082-5338
Practice Address - Country:US
Practice Address - Phone:760-749-1410
Practice Address - Fax:760-749-4122
Is Sole Proprietor?:No
Enumeration Date:2018-03-07
Last Update Date:2018-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA219534163WC1500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC1500XNursing Service ProvidersRegistered NurseCommunity Health