Provider Demographics
NPI:1083304380
Name:SUMMERLIN, MARK A (RD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:A
Last Name:SUMMERLIN
Suffix:
Gender:M
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1150 MONTE VISTA DR
Mailing Address - Street 2:
Mailing Address - City:BOSQUE FARMS
Mailing Address - State:NM
Mailing Address - Zip Code:87068-9238
Mailing Address - Country:US
Mailing Address - Phone:505-480-5752
Mailing Address - Fax:
Practice Address - Street 1:4701 MONTGOMERY BLVD NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87109-1219
Practice Address - Country:US
Practice Address - Phone:505-727-7022
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-10
Last Update Date:2023-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMLD2023090133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered