Provider Demographics
NPI:1598376873
Name:STEVENS, MARTHA (RD)
Entity Type:Individual
Prefix:
First Name:MARTHA
Middle Name:
Last Name:STEVENS
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:MARTHA
Other - Middle Name:
Other - Last Name:FULLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RD
Mailing Address - Street 1:510 E STONER AVE
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71101-4243
Mailing Address - Country:US
Mailing Address - Phone:318-990-5025
Mailing Address - Fax:
Practice Address - Street 1:510 E STONER AVE
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71101-4243
Practice Address - Country:US
Practice Address - Phone:318-990-5025
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-11
Last Update Date:2020-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered