Provider Demographics
NPI:1043860968
Name:MARTIN, ILONA (MS, RD, LDN, CNSC)
Entity Type:Individual
Prefix:
First Name:ILONA
Middle Name:
Last Name:MARTIN
Suffix:
Gender:F
Credentials:MS, RD, LDN, CNSC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:117 ELLENFIELD ST
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02905-4541
Mailing Address - Country:US
Mailing Address - Phone:401-444-5640
Mailing Address - Fax:401-444-5462
Practice Address - Street 1:1454 S COUNTY TRL
Practice Address - Street 2:
Practice Address - City:EAST GREENWICH
Practice Address - State:RI
Practice Address - Zip Code:02818-1749
Practice Address - Country:US
Practice Address - Phone:401-444-0931
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-12
Last Update Date:2019-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RILDN01030133VN1004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133VN1004XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Pediatric