Provider Demographics
NPI:1114544723
Name:MARTIN, KATHERINE JOHANNA (RD)
Entity Type:Individual
Prefix:MISS
First Name:KATHERINE
Middle Name:JOHANNA
Last Name:MARTIN
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:449 TARTAN CT
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28311-1694
Mailing Address - Country:US
Mailing Address - Phone:623-229-3353
Mailing Address - Fax:
Practice Address - Street 1:449 TARTAN CT
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28311-1694
Practice Address - Country:US
Practice Address - Phone:623-229-3353
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-30
Last Update Date:2020-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCL003504133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty