Provider Demographics
NPI:1407931736
Name:CAMACHO, MARTHA MUNN (MS, RD, LDN)
Entity Type:Individual
Prefix:
First Name:MARTHA
Middle Name:MUNN
Last Name:CAMACHO
Suffix:
Gender:F
Credentials:MS, RD, LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1612 BRAMBLE DRIVE
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27712-1212
Mailing Address - Country:US
Mailing Address - Phone:919-471-6561
Mailing Address - Fax:
Practice Address - Street 1:1301 FAYETTEVILLE ST
Practice Address - Street 2:LINCOLN COMMUNITY HEALTH CENTER
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27701
Practice Address - Country:US
Practice Address - Phone:919-956-4042
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCL000158133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
11456OtherREGISTERED DIETITIAN
NCL000158OtherLICENSED DIETITIAN NUTRIT