Provider Demographics
NPI:1598123499
Name:MARTIN, DESIREE
Entity Type:Individual
Prefix:
First Name:DESIREE
Middle Name:
Last Name:MARTIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:DESIREE
Other - Middle Name:
Other - Last Name:D'AMICO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:140 ALLEN RD
Mailing Address - Street 2:
Mailing Address - City:BASKING RIDGE
Mailing Address - State:NJ
Mailing Address - Zip Code:07920-2976
Mailing Address - Country:US
Mailing Address - Phone:908-604-7800
Mailing Address - Fax:973-290-8370
Practice Address - Street 1:140 ALLEN RD
Practice Address - Street 2:
Practice Address - City:BASKING RIDGE
Practice Address - State:NJ
Practice Address - Zip Code:07920-2976
Practice Address - Country:US
Practice Address - Phone:908-604-7800
Practice Address - Fax:973-290-8370
Is Sole Proprietor?:No
Enumeration Date:2016-02-05
Last Update Date:2018-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
133N00000X
NJ86033841133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No133N00000XDietary & Nutritional Service ProvidersNutritionist